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_ PSYCHOSOMATIC MEDICINE MONOGRAPH II-III _
THE TRAUMATIC
NEUROSES OF WAR |}
BY
ABRAM KARDINER, M.D.
FORMERLY ATTENDING SPECIALIST
U. S. VETERANS HOSPITAL NUMBER 81
FORMERLY INSTRUCTOR IN PSYCHIATRY
CORNELL UNIVERSITY
AND
ASSOCIATE IN PSYCHIATRY
COLUMBIA UNIVERSITY
- 1941 +
PUBLISHED WITH THE SPONSORSHIP OF THE
COMMITTEE ON PROBLEMS OF NEUROTIC BEHAVIOR
DIVISION OF ANTHROPOLOGY AND PSYCHOLOGY
NATIONAL RESEARCH COUNCIL, WASHINGTON, D.C.
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‘
THE TRAUMATIC
NEUROSES OF WAR
a
i i
PSYCHOSOMATIC MEDICINE MONOGRAPH II - III
THE TRAUMATIC
NEUROSES OF WAR
BY
ABRAM KARDINER, M.D.
FORMERLY ATTENDING SPECIALIST
U. S. VETERANS HOSPITAL NUMBER 81
FORMERLY INSTRUCTOR IN PSYCHIATRY
CORNELL UNIVERSITY
AND
ASSOCIATE IN PSYCHIATRY
COLUMBIA UNIVERSITY
EQAI.*
PUBLISHED WITH THE SPONSORSHIP OF THE
COMMITTEE ON PROBLEMS OF NEUROTIC BEHAVIOR
DIVISION OF ANTHROPOLOGY AND PSYCHOLOGY
NATIONAL RESEARCH COUNCIL, WASHINGTON, D.C.
BDITORIAL BOARD
MANAGING EDITOR: FLANDERS DUNBAR
FRANZ ALEXANDER
Psychoanalysis
DANA W. ATCHLEY
Internal Medicine
STANLEY COBB
Neurology
HALLOWELL DAVIS
Physiology
EDITORS
FLANDERS DUNBAR
Psychiatry
CLAR
K L. HULL
Psychology
HOWARD S$. LIDDELL
Comparative Physiology
GROVER F. POWERS
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PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
FOREWORD
THE TRAUMATIC NEuROsIs has long been a troublesome medical and
forensic problem. The medical aspects are fundamental because it is
the resolution of these problems upon which all other social issues
depend. Until the war of 1914-1918 this neurosis received but little
attention. The main problem in connection with it was whether to
account for the symptoms on the basis of organic or “functional”
hypotheses. Moreover, the neurosis usually carried the name of the
provoking agent, like lightning neurosis, railroad spine, shell shock,
etc.
The neuroses incidental to the great war made the world neurosis-
minded. They were studied with more care than at any time pre-
viously, and the literature is encyclopedic. Explanations of this
neurosis on a functional basis came largely from the influence of
psychoanalysis. The work of W. H. R. Rivers and William Mc-
Dougall was highly significant, as well as that of Ferenczi, Abraham,
Simmel and Jones. Freud never discussed this neurosis systematically,
but made some extremely important observations about it in 1921.
Between this work and the present time lie the experiences with
the chronic neuroses of the last war. This taught us much about
psychopathology, treatment, and the complicated forensic issues con-
nected with it. Nevertheless the conclusions of this work did not get
much attention, and hardly influenced the conception of the peace-
time traumatic neurosis, which is the same in structure as those pre-
cipitated in war.
The current war has again brought to the foreground the problem
of the neuroses incidental to it. This time, however, the problem is
much more urgent because, owing to the widespread aerial bom-
bardment of urban centers, the traumatic neurosis is now no longer
likely to be confined to combatants. In fact the traumatic neurosis
bids well to be one of the commonest neurotic disturbances in the
world. It is difficult to predict the nature and scope of the medical |
vi THE TRAUMATIC NEUROSES OF WAR
and social problems that this new aspect will create, but there can be
no doubt that these problems, both psychiatric and social, will be of
prime importance. If we are not to repeat the errors made during the
last war, with its accompanying waste, important problems in organi-
zation and study lie ahead. In our preparatory efforts the experi-
ences of the last war and those in the current war should be our chief
guide.
This book purports to be a guide to the study, treatment and
postwar care of those neurotic disturbances which are incidental to
war. [he greatest stress in this work falls on the discussion of those
principles of psychopathology necessary to make these neuroses in-
telligible and to furnish a rational basis for therapy. This was re-
garded as the prime objective, for without this knowledge no
intelligent program for treatment, prophylaxis, and postwar care
can be formulated. In addition, an attempt is made to discuss the
forensic aspects of the traumatic neuroses, since so many of them be-
come government charges for a long postwar period. Treatment 1s
discussed at length only in connection with several chronic cases which
terminated successfully. This is in no way to be construed as indicat-
ing that therapy in these chronic cases is universally successful.
Most of the clinical material included in this book was gathered
while I was Attending Specialist in the Outpatient Department of
U. S. Veterans Hospital Number 81 during 1922 to 1925. All but
a few of the cases were studied there. Some of them were repeatedly
demonstrated to classes in psychiatry from 1923 to 1928. The case
which is the basis for the discussion on therapy was demonstrated in
person before the New York Society for Clinical Psychiatry in Feb-
ruary, 1924.
Although the purpose of the book is purely practical, the oppor-
tunity was used to discuss all the accessory data necessary to a more
complete understanding of this type of neurosis, and also to discuss
some pertinent issues in psychopathology. The reader not interested
in any but the clinical and practical aspects of these neuroses can
safely delete Chapters IV and V.
The material of this book was the subject of a paper originally
published in the Psychoanalytic Quarterly (Vol. 1, nos. 3-4), under
FOREWORD Vil
the title, “The Bioanalysis of the Epileptic Reaction.” In that paper
the emphasis was largely theoretical. The chief interest there was to
reconstruct the nature of the epileptic reaction. Some of the cases
there used are reproduced here. The clinical material in the present
book is much more extensive, however. As regards the psychopathol-
ogy, the conception of the traumatic neurosis is essentially the same.
However, the theoretical reconstruction has been considerably altered
and much simplified, this simplification being due to a change in the
operational concepts employed. The chief operational concept in the
first version was that of “‘instinct,”? and in order to describe the dy-
namics a good many obscure concepts had to be devised which were
not very helpful. These have all been deleted. I am indebted to the
publishers of the Psychoanalytic Quarterly for permission to repro-
duce some of the material published in the earlier work.
The short bibliography is no indication of the extent of my in-
debtedness to other writers on this subject. I have included in this
bibliography only those references of which I have been able to make
positive use.
For the consummation of this work I am indebted to: Dr. Walter
Treadway, through whom I received the opportunity to study these
neuroses; to the late Dr. George H. Kirby; to Dr. Adolph Meyer,
for discussions while the material was organized; to Dr. Sandor
Rado, for continual encouragement; and Dr. Otto Fenichel for a
very stimulating criticism of the above mentioned paper (Jwz.
Zeitschr. f. Psychoan., 1934).
I owe a great debt of thanks to the editors of Psychosomatic Medt-
cine, especially to Drs. H. Flanders Dunbar, H. S. Liddell and
Franz Alexander, for their editorial criticism and assistance in the
preparation of the book. I am also indebted to Dr. Harold Kelman
for studying the theoretical parts of the book, for some suggestions
on organization for treatment, and on problems for future research.
His experience with civilian and war traumatic neuroses was useful
to me as a check on my observations, and discussions with him were
useful in formulating my opinions on many matters.
New York A.K.
November 3, 19 40
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
CONTENTS
FOREWORD
PART Iz CLINICAL
I. INTRODUCTION
Il. SYMPTOMATOLOGY OF THE TRAUMATIC NEU-
ROSES
Pathoneuroses—Hypochondriasis
Schizophrenia
‘Transference Neurosis
Defensive Ceremonials and ‘Tics
Autonomic Disturbances
Sensory-motor Disorders
The Epileptic Symptom Complex
Summary
III. ANALYSIS OF THE SYMPTOMATOLOGY
War and the Traumatic Situation
What is a Trauma?
The Alteration of Adaptation in .
. Repetitive tics and ceremonials
2 ee, phenomena .
3. Sympathetic-parasympathetic shiaastetes
4. Syncopal phenomena
The Organization of the Neurosis
Constant Features of ‘Traumatic Neurosis, fac aihig
I. Fixation on the traumatic event
2. Dream life
3. Contraction of general level of fanctontne
4. Irritability
5. Tendency to aggression aiid diletice
6. Inhibitory phenomena
Regression or Disorganization
‘Traumatic Neurosis and Epilepsy
Conclusion
x THE TRAUMATIC NEUROSES OF WAR
PART II: THEORETICAL
IV. THE DEVELOPMENT OF THE EFFECTIVE EGO
135
Introduction: Methodology : 135
What is Adaptation? . 14!
Development of Adaptive Patierts 142
The Development of Maxtery—Antoriatlzation of Fu unctions 146
The Internal Environment and Its Réle in Activity 157
The Effective Ego and Failure Reactions _.. 160
Summary and Conclusions : : ; 169
V. PSYCHODYNAMICS . . 17%
Structure and Relations of the Action Syndrome _. 177
The Consequences of the Inhibition. 182
Nosological Considerations—The a 193
Summary and Conclusions , 198
PART I: PRACTIGAL
VI. COURSE, PROGNOSIS, DIFFERENTIAL
DIAGNOSIS | 209
Course ; : 209
Prognosis. 211
Differential eee : ' ; ; 252
VII. TREATMENT : . 216
Acute Cases . : ; 279
Treatment of Acute Conditions | . | j 217
Chronic Cases . ; 221
Further Points in Techetios . : 227
Hospital Organization for Treatment . ; 228
Prophylaxis and Civilian Morale : 230
Summary : . : ; 232
VIII. FORENSIC ISSUES | ; 233
IX. OPEN QUESTIONS AND FUTURE PROBLEMS _. 240
Questionnaire on Traumatic Status. : 242
BIBLIOGRAPHY . ; ' 247
INDEX : ’ ; : 253
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
PART I: CLINICAL
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PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
I. INTRODUCTION
THE TRAUMATIC NEUROSIS is the commonest neurotic disturbance of
war. This does not mean that the traumatic neuroses of war differ
in any way from the traumatic neuroses of peacetime or from those
following upon natural catastrophes like great fires and earthquakes.
Nor is the traumatic neurosis the only reaction to the war situation.
These latter may include every known neurotic and psychotic dis-
turbance occurring in peacetime, the only difference being that their
course is in no small measure altered both in tempo and intensity
from those that occur in peacetime. In addition to these, every pos-
sible variation of concussion syndrome with or without actual somatic
damage, and every conceivable emotional reaction to these injuries
may result from the war situation.
This book does not purport to treat of all the psychic disturbances
of war. It seeks merely to explore a highly specific syndrome which
can be called the traumatic neurosis. Its purpose is to establish the
symptomatology, criteria for differential HABBO, and to establish
a rationale for therapy.
The importance of this neurosis is due, not only to the severe in-
capacities which result from it, but also to the many and complicated
forensic problems which it brings in its wake. The chief of these is
the problem of compensation and the management of the veteran
with such a neurosis. A second type of problem presents itself in the
traumatic neurosis which refers purely to psychopathology, and in
this the significance of the traumatic neurosis becomes very great
indeed. These problems in psychopathology concern ‘first those of
method: namely, what criteria to use in establishing the sympto-
matology of this disease; what operational concepts are to be used to
establish the nature of the symptoms; the essential psychological
processes; and finally, what therapeutic indications follow upon the
conception of the illness derived from these sources.
During the last war several conceptions of these neuroses pre-
4 THE TRAUMATIC NEUROSES OF WAR
vailed. Those who were accustomed to the organic point of view
naturally regarded all the phenomena of this neurosis as due to the
direct effect of a widely disseminated organic lesion. The support for
this idea came from the vast number of neuroses associated with
severe concussion syndromes, with indubitable evidence of the ex-
istence of actual organic lesions. For practical purposes this concep-
tion of the traumatic neurosis did very little harm, for it encouraged
a regime of supportive treatment; and even if many of these cases
did not recover, the residuals were still attributed to the organic in-
jury. This point of view was, however, seriously brought into ques-
tion when large numbers of neuroses were found with no evidence
of concussion but still with symptoms in many ways like those in
which the evidence for organic injury was unquestionable. This jus-
tifies the conclusion that the symptoms resulting from the concussion
were not direct evidence of organic lesions but that they were the
indirect effect of these lesions upon the tota] adaptation possibilities
of the individual and that the interference in adaptation could occur
with or without organic injury.
A second point of view exploited in connection with this symptom
complex was that the traumatic neurosis was “psychogenic” in char-
acter. Whereas this point of view was very plausible, one again
needed definite criteria. One group of authors elected to describe the
illness as due to specific conflicts occasioned by the war situation as
against the peacetime situation; that is, the peacetime ego was con-
trasted with the wartime ego, and the conflicts were entirely in terms
of the issue of self-preservation as against ideals of heroism, patriot-
ism, and the like. Whereas it is plausible that such conflicts do exist
and undoubtedly contribute much to the ultimate picture of the
neurosis, it must again be pointed out that these neuroses are ex-
tremely common in peacetime when the issue of peacetime versus
wartime ego does not exist. Furthermore, such conflicts do not in
any way explain the symptomatology of the disease. In other words,
many factors may contribute to the formation of the traumatic syn-
drome, organic lesions, self-preservative interests, and conflicting
ideals. The essential problem of psychopathology is to explain the
manner in which the symptoms are constructed.
— Ss ee oe
INTRODUCTION 5
From the point of view of interpretation of the symptoms, that is,
their origin and meaning, psychoanalysis made some interesting sug-
gestions. Psychoanalysis offered its particular conception of the neu-
rotic process as it was known up to that time (1918). The neurotic
process was conceived as an interference with certain instinctual
drives, and the symptom could be accounted for on the basis of re-
gressive substitute formation. In this regard the traumatic neurosis
did not fall easily into the category of the previously well-studied
transference neuroses, hysteria and compulsion neurosis. Efforts were
made to create new classifications. Traumatic neuroses were consid-
ered “actual neuroses,” organ neuroses, pathoneuroses, pregenital
conversion hysterias, narcissistic neuroses, and so forth. These classifi-
cations, in extremely confusing terms, offered little basis for psycho-
therapy. In fact, the therapeutic measures used successfully in treat-
ing these neuroses had very little to do with the conception of the
psychopathology.
From the point of view of psychopathology the orientation in
terms of instinct was very misleading. The pathology of the transfer-
ence neuroses was worked out on a series of illnesses in which the
sexual instinct was supposed to be directly involved. In the case of
the traumatic neuroses, the psychopathology had to be accounted for
indirectly as due to the operation of the castration complex. It as-
sumed that one could track down the pathology of an interference
with self-preservation with the same criteria used in establishing the
interference with the sexual instinct, notwithstanding the fact that
up to 1918 there was no success in describing the pathology of the
so-called ego instincts, and that “self-preservation” was the name of
a result and not of an instinct.
The point of view of this volume is somewhat different. Let us
make the general assumption that elementary drives do exist. But
we cannot today any longer assume that the phenomena we observe
in psychopathology are in any way to be construed as direct evidence
of the operation of this, that, or the other instinct. The reason is that
the object of study is always a personality as a whole. We observe
functional and functioning units and not drives. These units are
either effectual or ineffectual as regards their ultimate purposes for
6 THE TRAUMATIC NEUROSES OF WAR
the personality as a whole, and the question as to whether or not they
furnish direct evidence of “instincts” is irrelevant. What we observe
in the traumatic neurosis is a characteristic interference with certain
effectual units, the ultimate purpose of which may be self-preserva-
tion or preferably, a certain kind of effectual adaptation. This is quite
a different thing from saying that we observe an interference with
the instinct of self-preservation. With this shift in point of view, the
emphasis in the psychopathological data falls in a new direction. The
concern with the question about the content of the manifestations
(that is; is it narcissistic, pregenital, and so on) yields to the question
as to which executive function is interfered with and why. In other
words, emphasis is shifted from content to form. The failure due to
describing the neurosis in terms of content was the fact that it did
not take in the main factors in the psychopathology. If one describes
a neurosis as narcissistic, one has yet to describe the difference between
narcissism as it occurs in manic depressive psychosis, epilepsy, schizo-
phrenia, or the traumatic neuroses.
In short, it is the purpose in this book to describe these neuroses
from the point of view of the field, or action syndrome, rather
than that of instinct. This must not be construed as a denial of drives;
it merely questions the assumption that imstinct or drive is an ade-
quate operational concept that can do justice to the clinical facts and
offer a basis for therapy.
The traumatic neuroses can be studied in the acute or stabilized
forms. For the purposes of this book the stabilized forms offer the
best opportunities. Recent literature on the current war demonstrates
that the symptomatology of this syndrome is no different today than
it was during the last war (64). It further demonstrates that in the
acute stages no definite opportunity exists for the study of this
neurosis.
The plan of the book is first to describe the clinical forms of the
traumatic neuroses; then to determine, from the analysis of the
symptomatology, what aspects of the personality are involved; to
arrive at some working definition of trauma, thence to a discussion
of the psychopathology, and finally to a discussion of therapy and the
forensic problems involved.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
Il. SYMPTOMATOLOGY OF THE TRAUMATIC
NEUROSES
THE syMPTomMs of the traumatic neuroses vary according to how soon
they are observed after the trauma. This is particularly the case with
the neuroses of war. The symptoms can be described as acute, transt-
tional, and stabilized forms. The time interval between the acute and
stabilized forms is generally two or three weeks. There are excep-
tions to this, as will be seen from a number of the cases below, some
of which take as long as six months to become stabilized. The cases
which stabilize most rapidly are the sensory motor disturbances; those
which take longest, the ones terminating in epileptiform phenomena.
The cases which, in the stabilized form, have purely autonomic (sym-
pathetic and parasympathetic) phenomena have the most varied
symptomatology and generally represent residuals of a long series of
changing symptoms.
The acute symptoms may be:
. Symptoms of shock, with typical manifestations of terror.
. Comatose conditions.
. Maniacal reactions, excitements, and fugues.
. Delirious reactions.
. Paralyses and sensory disturbances, without other manifesta-
tions.
Mma WwW bd &
For purposes of study the stabilized forms of the neurosis are the
most important. For the greater part, once this stabilized form is
reached, it can remain stationary for as long as ten years—the longest
period I have had the opportunity to observe them.
PaTHONEUROSES—H YPOCHONDRIASIS
Case 1. The patient, a soldier twenty-five years old, fell with an
airplane from a height of one thousand feet. He struck the ground
with great violence but was not killed. He could remember nothing
after the moment of striking.
8 THE TRAUMATIC NEUROSES OF WAR
During his convalescence he was told that, immediately after the
injury, he acted as if he were not unconscious; in fact, he had helped
himself into the ambulance and had spoken to the woman who as-
sisted in his rescue. But for all these circumstances he had a complete
amnesia. He was in a state of “unconsciousness” for five days, Dur-
ing that time he remembered a dream in which he had an enemy
helmet on his head and was engaged in tearing it off. After he re-
gained consciousness he was told that during his sleep he had torn
a plaster of Paris cast from his head.
During the past six years the patient had had falling dreams two
or three times, and he remarked that this was about the frequence
with which he used to have falling dreams before the accident. He
had had a certain amount of fear of high places, fear of driving, but
hardly to a degree of being distinctly neurotic.
His chief preoccupation was with a facial deformity which had
resulted from this fall. He now carried about in his coat pocket a
picture of himself as he was before the accident and, gazing at it fre-
quently, continually bemoaned this disfigurement. As a matter of
fact, no one would have realized that the young man had suffered a
deformity of the face, unless he had previously known the patient.
There was nothing but a slight asymmetry and a flattening of the
nasal bridge. In this case the effects of the trauma were completely
dissipated in the preoccupation with the deformity it had caused.
Here it is important to note the rapid disappearance of the typical
dream life and the absence of irritability, aggressiveness, and inhibi-
tions. But in their place was a severe hypochondriasis. This type of
outcome is extremely rare. The hypochondriasis is not nearly so
prominent in cases where the injury is inflicted on a part less im-
portant, from the narcissistic point of view, than the nose. The reac-
tion to the traumatic situation consists of a preoccupation with his
appearance. The general formula for his obsessive thinking is, “I
have lost the claim to social recognition and love, and I do not love
myself any more.” Such a syndrome was described by Ferenczi under
the name of pathoneurosis. This type is one of those responsible for
the conclusion that those who are injured do not develop a traumatic
neurosis.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES- 9
SCHIZOPHRENIA
Case 2. The patient, twenty years old, was intellectually below
average and was always engaged in unskilled labor. While in service
he was “buried by a shell.”? He was taken to a hospital but did not
remember any of his immediate symptoms. He did, however, remem-
ber that most of the symptoms of which he now complained began
after his trauma. Symptoms included persistent insomnia, typical
nightmares of things being on fire, people being killed, he himself
being annihilated. He had distinct delusions of reference, of people
talking about him, and an irresistible impulse to strike people on the
street. He thought other people on the street offended him. He was
also constantly hallucinating the voice of his dead mother, who was
always reassuring him not to be afraid. Extremely superstitious, he
was afraid of seeing ghosts, afraid of crossing the street. He had delu-
sions about a foul odor’s emanating from his person. He thought he
“smelled like a dead rat.” He could not adjust himself to his father,
with whom he always quarrelled. So difficult had relations between
them become, that his father once put him out of the house. The rea-
sons for these quarrels were usually some trifling matter, but the
patient was evidently responsible for all these disturbances. At the
time of his treatment he was better than he had been at any time
during the preceding five years.
A simple paranoid schizophrenia, this case is of special interest
because, besides the outspoken schizophrenic features, some of the
features are distinctly characteristic of a traumatic neurosis. A great
deal of resemblance lies between the persecutory fantasies of a para-
noiac and the dreams of a traumatic neurotic. In paranoia the patient
is persecuted by the individual by whom, unconsciously, he expects
to be loved. In the traumatic neurosis he is persecuted, in a similar
way, by the environment, which has for the time being withdrawn
its protective character. The fantasy of world destruction in schizo-
phrenia is apparently a manner of perceiving in the outer world what
is really happening within himself. The paranoid delusion, in the
above case, cannot be considered in any way a transference symptom
of the reaction to trauma because, as a rule, the secondary defenses
10 THE TRAUMATIC NEUROSES OF WAR
of the traumatic neurosis have a psychological elaboration which
usually has no resemblance to the paranoid delusion. I have, how-
ever, seen several cases in which the quality of the symptom was pre-
eminently that of the traumatic neurosis, but in which persecutory
ideas were present occasionally and intermittently. Possibly the
trauma, in this and in similar cases, serves rather as the occasion for
touching off a deep-seated latent schizophrenia, but it seems also to
impart to the resulting clinical picture something of the characteristics
found in all traumatic neuroses.
It is worth noting that transient schizophrenias, many of which
terminated in complete recovery, were common during the war. The
trauma can only be considered a precipitating factor, hardly a causa-
tive agent that provoked the illness. In the light of what we know
about the characteristics of traumatic neuroses, a schizophrenic reac-
tion is, conceivably, one of the effects to be expected; the trauma
gives the already enfeebled adaptive resources an additional setback.
‘TRANSFERENCE NEvuROSIS
Case 3. The patient was twenty-eight years old. Since fourteen,
he worked at various trades and finally became a pipe fitter. Prior
to service he got into some difficulties with the law because of his
participation in street brawls. He was evidently a very pugnacious
individual.
The life of a soldier apparently agreed with him. He enlisted for
service on the border but was recalled to serve in France. Never
wounded, he had only one traumatic experience in the form of mild
gassing, in August, 1918. Neither during his convalescence nor im-
mediately thereafter did he have any symptoms, but his breakdown
occurred after returning to his country. The occurrence of the first
symptoms after the return to a peaceful environment is usually more
apparent than real. As a matter of fact, there usually is a continua-
tion of the same symptoms that were present in the danger zone, but
they are not noticed there. They are usually felt when the external
turmoil has ceased. ¥
His symptoms were irritability, depression, tremors, sensitiveness
to noise—so much so that he could not resume any form of work
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 11
involving constant noise. He had spells of aggressiveness and un-
reasonable temper; vertigo was a pronounced symptom, often keep-
ing him in the house. In addition to these, he had several well-defined
phobias; fear of riding in the subway and fear of insanity. During
the day he was obsessed with recollections of the scenes of war, and
at night he used to have typical nightmares.
The capacity for displacement, in this case, is quite pronounced.
His fears displaced themselves on a great many situations and had
the character of true symbolic displacements and not of superficial
resemblances to his war experiences, as is so frequently found in
traumatic cases. He had constant fears, for example, that someone
was entering his house, fears that his child was going to die, fears
that something would happen to his wife or to other members of the
family.
The chief interest in this case lies in the fact that the anxiety of
this type of patient is very readily recognized as such. The escape
from the repressed ideas takes place in much the same way as it does
in the ordinary transference neurosis. The patient accordingly showed
himself, to a large degree, accessible to psychoanalytical therapy. The
neurotic picture had two different aspects, one of them belonging to
a psychosexual conflict, the other to a traumatic neurosis, and the
two communicated freely with each other. His accessibility to treat-
ment brought good results. The remarkable feature is the fact that
his displacement phobias were much more readily removed than his
secondary symptoms resulting from the traumatic neurosis—his sen-
sitivity to noise, his irascibility, etc.
The patient married after his return from abroad “in order to
cure himself.” The transference symptoms were very largely super-
imposed upon and independent of his irascibility. However, in the
course of treatment, the patient was able to utilize his marriage as
he originally designed. His newly-born child came to be the focus
of his entire interest and attention.
Case 4. The patient was thirty years old. From his past history he
gave a typical psychoneurotic picture. He was never in love with any
woman; he was unmarried; his sex life was far from normal. His
12 THE TRAUMATIC NEUROSES OF WAR
symptoms were a general and a constant apprehensiveness, fatigabil-
ity, and insomnia. He had grown away from all his social connections,
was quite seclusive, and according to his own description, very unlike
his former self. Since the war, his sexuality had been more repressed
than ever. He had the typical dreams of the traumatic neurotic—of
war scenes, particularly those in which he was being buried by shells;
of being in close spaces; of being in the trenches.
He had one very pronounced phobia, the fear of riding in the sub-
way; while in the subway he had characteristic anxiety crises—a feel-
ing of discomfort, a choking sensation, an uncontrollable anxiety. He
would heave a sigh of relief when the train reached the surface.
During the war he was exposed to many petty traumata, but the
most distressing experience he could recall was that of “going over
the top.” He was on several occasions buried in the trench, where
he saw several of his companions killed. Symptoms began shortly
after he was taken away from active duty.
The predominance of displacements in this case is quite obvious.
To all intents this patient had an ordinary claustrophobia. The pre-
disposition to neurosis was present prior to service, and one can readily
see that the fear of the subway serves to carry off anxiety from both
his egoistic and his sexual conflicts. This is typical transference neu-
rosis. The traumatic experience aggravated a previous neurotic char-
acter disturbance.
Case 5. The patient, thirty-six years old, was married prior to
service. Domestic life was very unhappy, and service was undertaken,
in part, as a release from his difficulties at home. When he first pre-
sented himself, his chief concern was with the anxiety which was
occasioned by riding in a train. This symptom, he said, made tt impos-
sible for him to go to work and thus interfered with his economic
independence. The symptom, he also stated, arose while he was 1n
service. His dreams were of the usual distressing character, most
often concerned with being in a vehicle which was colliding with
another. His dreams, however, as well as his daytime fantasies,
usually contained a good deal besides this. He saw himself wounded
as a result of the collision and mourned over by his wife and children.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 13
He described other symptoms—intensive vertigo, some gastroin-
testinal disorders, tremors, irritability. He was also very quarrelsome.
An investigation of his phobia showed that it was connected with
a special feature of train-riding, that he was never uncomfortable
while the train was in motion, and that it showed itself only after
the brakes were applied. He then grew very tense and feared a col-
lision. Consciously he never associated his anxiety with any experience
he had had. However, the patient had actually been in a collision.
He was riding a motorcycle, without lights, on a dark night, and
while making a turn in the road, he ran into a stone wall. Unconscious
for some time, he regained consciousness in a hospital. Shortly after-
wards he began to have distressing dreams usually involving some
collision. After a while these dreams were elaborated into fantasies
which indicated that the traumatic experience was serving the func-
tion of a displaced conflict. The following is a typical dream: “I was
riding in the automobile when we collided with another car head-on.
I was taken out of the car, all mangled, and my wife and children
were standing over me, weeping.”
We are now in a position to understand the phobia. The anxiety
occurs when the brakes are applied; it is, to all intents, a defense
mechanism which protects him from a recurrence of his traumatic
experience. However, the dreams of collision have a definite relation
to his sex life. After his trauma, the patient became completely im-
potent. He had a very ambivalent attitude toward his wife and, as
we noted before, went into service with the unconscious motive of
becoming incapacitated. His symptoms now kept him from going to
work, and we find that the patient’s interests were now overtly con-
fined almost entirely to himself. His children and his wife hardly
ever occurred in his associations.
The mechanism of defense in his phobia, as far as it was related
to the actual trauma, was readily accepted; but when any step was
made in the direction of analyzing the effects of the trauma in rela-
tion to his family conflict, I encountered the greatest resistance. He
was able to ride in trains without anxiety, but his impotence, his
irascibility, etc., persisted unabated. Moreover, he began to shift his
interest entirely upon a hypochondriacal symptom which, prior to
14 THE TRAUMATIC NEUROSES OF WAR
this time, was latent. The vertigo now became his most distressing
complaint. He was a building contractor; his vertigo was most pro-
nounced in high places, thus constituting a perfect defense against
his work. He then became much preoccupied with some gastroin-
testinal symptoms which grew more intense as time went on. He
insisted on X-rays, numerous gastrointestinal examinations, pro-
toscopies, and operations. He also insisted that he was subject to fre-
quent hemorrhages from the bowels.
Although it is premature at this point to discuss dynamics of the
disease, to make clear some of the transference reactions of these
patients, I must anticipate. The physician, in these compensated cases,
stands for the government, which stands for mother (breast). Any
attempt to deal with this dependency constellation is resisted. De-
pending on the previous historical development of the subject, he
will flee from one symptom to another indefinitely, and if one gets
anywhere near this oral dependency, he will not infrequently resort
to flight from treatment. If the dependency is taken by force—by a
reduction of compensation or the like—this precipitates the most
violent aggression against physician (mother). The flight into other
symptoms with cessation of treatment is the rule in these cases.
We see, therefore, that the traumatic neurosis, per se, occupied a
relatively unimportant place in the clinical picture of the last case
cited. The defense mechanism which directly referred to the trau-
matic experience was very readily removed. However, that part of
his neurosis which signalized the trauma as a symbolic “castration”
formed indeed the largest bulk of the clinical picture. The case 1s,
to all intents, a transferance neurosis released by the trauma.
These cases are of great importance; they make up the largest
volume of those cases which in peacetime are considered “traumatic
hysterias.” They differ in no essential respect from the transference
and narcissistic neuroses. Inquiry into their personal histories usually
reveals infantile anxieties and subsequent psychosexual difficulties of
gross character which, prior to the trauma, showed themselves in the
--form of inhibitions. In Case 3 the claustrophobia gets its special char-
——. acter from the experience in the trenches. These cases, in which
transference mechanisms abound, in which the dreams and the sec-
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 15
ondary defenses show gross evidence of psychosexual conflicts, have
no claim to the name of traumatic neuroses. How much a given
clinical picture belongs to one or to the other is not very difficult to
decide. It often suffices to hear merely the narrative of the type of
dream which the patient has. In this regard the true traumatic neu-
rosis is very easy to distinguish from the transference neurosis. The
stereotype of the dream life of the traumatic neurotic is pathogno-
monic, as are likewise the secondary defenses and inhibitions.
DEFENSIVE CEREMONIALS AND Tics
A large group of cases possess symptoms which are chiefly uncon-
scious defense reactions against the original trauma. This may persist
in the form of a tic which, when analyzed, shows itself to be a defen-
sive reaction actually engaged in during the original traumatic event.
The defensive reaction remains, as it were, petrified, and the clinical
picture looks like the photograph of a person engaged in running or
like a pointer fixed in the posture in which he locates his prey. It
may be a more complete elaboration of a defensive reaction which
was not carried out on the original traumatic occasion. Of the first
type we may mention a very simple case. A sailor was on board a
battleship, when, without his being warned, a turret situated above
and to the right of him discharged a volley. He was thrown to the
ground, and since that time he has had a persistent tic of the head
to the left. Consciously, the patient has no knowledge of the purpose
of this tic, and he has long since forgotten the connection between
the action and the purpose it served. Another common reaction type
of this variety is shown by the defensive attitude of patients constantly
on the alert for something to happen. Thus a soldier received a
severe shock on the battlefield when a dud landed in front of him.
Whenever he sees something that is “almost going to happen”—such
as a child crossing the street and being “almost killed”’—he is thrown
into a panic of expectancy.
In the second group the defense ceremonials have the nature of
compulsory acts which the patient carries out without knowing ex-
actly why, but which relieve him of anxiety. The case described below
is of this character. In this case a group of ceremonials, impulsive
16 THE TRAUMATIC NEUROSES OF WAR
postures, and attitudes are, so to speak, correctives. These activities
are usually carried out with no more control of the will than is the
ordinary compulsive ritual.
A third, though very uncommon, type is that in which a series of
tics involves practically every part of the body. This is, so to speak,
a fragmented, interrupted, and piecemeal convulsion. One such case
was observed over a prolonged period. No part of the body was im-
mune from these tic-like actions. In these generalized tics is a lack
of the codrdination and purposiveness encountered in the simple
forms mentioned above.
The single and multiple tics are active most of the time during
the day, but the patient is quiet after he retires. In this regard these
tics differ in no way from ordinary tics of peacetime. They are aggra-
vated by any effort or by sudden stimuli. Usually patients having
these tics do not show the characteristic dream life. This symptom is
evidently a sufficient outlet.
I have stated that the symptoms of compulsion neurosis are rarely
found in traumatic cases. But here I recall one case in a soldier who
was blown up by a shell. He had the usual nightmares and a few
spells of unconsciousness. But these symptoms disappeared to give
way to a series of tics involving every part of his body and giving to
his intentional muscular movements an athetoid character. This pa-
tient had a compulsion to touch certain objects he would see, but he
felt compelled to touch no specific object, and never the same object
twice. I could not succeed in allocating any mechanisms in this case.
He is the only case in which I have ever seen symptoms of a true
compulsion. Unfortunately, opportunity did not present itself to
study him more thoroughly.
Case 6. This patient was twenty-four years old. There was no his-
tory of neurotic traits. He had never suffered from any form of
syncope, fainting spells, or convulsions. His sex life, as far as could
be ascertained according to the usual criteria, was quite normal. He
was a sociable fellow and enjoyed the pursuits fitted to his sex and
age. Hardly out of high school, he enlisted in the army for purely
patriotic motives. No history of friction or maladaptation at home
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 17
existed to serve as an unconscious motive for his departure. On ex-
cellent terms with his father, he also had, as far as could be elicited,
quite a normal attitude toward women.
During his service in the army he suffered but one injury and that
not a serious one; he was mildly gassed on one occasion. As a result
of this, he had a mild chronic bronchitis. He was thus disqualified
from doing certain forms of work, especially that connected with
irritating fumes. Since his discharge from the army, he found that
his efficiency was much impaired, He worked as a post-office clerk,
then tried business for himself but was not very successful. His neu-
rotic illness interfered with his efficiency to such a degree that he
applied for and received vocational training. Between the time he
left the service and the time he came under treatment, he had married
and now had one child.
His physical examination was negative except for a few sibilant
rales in the chest. Neurological status was negative. On mental ex-
amination I found only the evidence of an anxiety hysteria. During
the daytime he suffered merely from a vague apprehensiveness.
The salient feature of his neurosis was a typical hysterical trance
which overtook him just at the point of falling asleep and in the
brief interval between sleeping and waking. Other features of the
trance included his becoming stiff all over, an intense anxiety, and
violent palpitation of the heart. “I feel as though I were passing out
of the world, as if I were trying to fight death.” These spells came
about two or three times a week, sometimes as often as six times in
one night. Naturally he feared going to sleep.
The neurosis began several days after he had been removed to the
hospital, following his gassing (1917) and was initiated by anxiety
dreams of the horrible scenes he had witnessed in the trenches. Sev-
eral days later he had the first of these twilight terrors which per-
sisted for five years thereafter. During this interval of five years he
dreamed frequently of war scenes, always with anxiety.
After the attacks had troubled him for many months, he spon-
taneously devised a method for preventing their occurrence. What he
did cannot be regarded as anything short of a compulsive ritual. It
consisted of lying, face down, on his pillow, burying his nose in the
18 THE TRAUMATIC NEUROSES OF WAR
pillow and putting his hands alongside his face. In this prone position
he had a feeling of security, and though he could not stop one of his
spells by assuming this position, he was quite sure that, if he took
this position on going to bed, he would not have a spell. He remem-
bered often being awakened by one of these twilight states to find
himself in the supine position.
When asked to explain what relation his ceremonial would pos-
sibly have to do with warding off one of his spells, he was completely
at a loss. Evidently the meaning of it was entirely unknown to him,
and ordinary introspection would be of no use in unraveling its mys-
tery. The patient was asked to tell quite freely what occurred to
him when he thought about this posture. His associations to the
ceremonial were as follows: 1) swimming, 2) coitus, 3) “taking
cover.” Swimming is quite naturally a birth symbol, and here the
patient, like many others, associates the trauma with birth. In con-
nection with coitus was a long series of associations, all of which dealt
with the subject of more children. He had but one child, his economic
situation being so uncertain that he could not take the chance of hav-
ing more. This led to a very complicated series of attitudes and reac-
tions based on the issue of compensation, all to the effect that he
needed compensation and could not get on without it, that his illness
had robbed him of every bit of self-confidence he had ever had, and
so on.
The association of “taking cover” led him back to the original in-
jury, the only one he had received while in service. He then told
how he happened to be gassed. On guard duty with five other men,
he was awakened one morning by the sound of exploding shells,
and in this semiconscious state he saw a large shell explode about
twenty feet in front of him. On seeing the red flare, he immediately
began putting on his gas mask. He remembered trying to hold his
breath in order not to catch any of the gas before the mask was ad-
justed. And he then remembered that holding his breath was one
of the features of his anxiety attacks and also one feature of the
ceremonial. In the few seconds between seeing the flare and putting
on his mask, his neighbor accidentally brushed it off just as he had it
fitted and thus dislocated it. This resulted in his breathing the gas,
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 19
as he could no longer hold his breath. Then he lay there, face down,
overcome, for a period of about half an hour, when he was removed
to a yard station. He was much more frightened then seriously
gassed.”
Little doubt remains after this description, of what the neurosis
consisted and what scene the patient was re-enacting in the trance and
the associated ceremonial. The facts that the trance was accompanied
by anxiety, palpitation and holding his breath and was relieved by
his taking a position which he associated with “taking cover” and that
this was accompanied by movements very like the motions of a man
trying to fasten a gas mask to his face, indicated the typical phenom-
enon of traumatic neurosis, the repetition phenomenon. Here, again,
is a symptom and a few secondary elaborations based on a traumatic
experience which jeopardizes the individual’s life; the ideational con-
tent is completely lost (repressed); the emotional reactions which
originally accompanied it are split off and recur with monotonous
regularity on the same occasion, namely the interval between sleep-
ing and waking. Being on guard duty, he was not completely asleep
at the time the shell exploded; his hysterical symptom guarantees
an excessive amount of anxiety and preparedness which was absent
on the original occasion. On each successive occasion he holds his
breath, puts on his mask, and, thus prepared for a gas attack, he can
go to sleep peacefully.
Several other features of the case must be included in this descrip-
tion. The issue of government dependency was intimately bound up
with his neurosis, although it did not call forth the symptoms of the
trance. The patient, as mentioned above, was in vocational training
and was, in the meanwhile, being supported by the government. His
training officer, owing to some misunderstanding, threatened to put
him out of training for insufficient codperation. For a short time he
was without pay. During the interval the patient went into a pro-
found depression and developed a new set of symptoms, fear of
poverty and fear of insanity. With the adjustment of his difficulties
in training, these symptoms disappeared. Interesting to note is that
* This case was presented in person before the New York Society of Clinical Psy-
chiatry, February, 1924.
20 THE TRAUMATIC NEUROSES OF WAR
the old traumatic neurosis did not disappear under these conditions;
he developed, on this occasion, new symptoms which he never had
before. There is reason to believe that the symptoms which arose in
connection with compensation link up very closely with psychosexual
conflict but that the traumatic neurosis enjoys almost complete
autonomy.
In this case, we note, the patient did not realize that the hysterical
trance was directly connected with the traumatic experience. In other
cases the patient seems to know that a certain given phenomenon is
connected with a traumatic experience. On close examination it
proves, however, that he is not much wiser than the one who is en-
tirely ignorant of this fact.
This type of case is theoretically of great importance. We see here
a repetition mechanism of high degree of organization; it is purpose-
ful in making a correction over a situation which threatened the
patient with annihilation. Capable also of symbolization and carrying
a deep-seated psychosexual conflict, this type is the most highly or-
ganized form found in the various reactions to trauma, excepting, of
course, the pure transference type. This patient’s anxiety states have
something of the quality of twilight states, which we shall subse-
quently encounter in the epileptic type.
This last case is important for many other reasons. It demonstrates
the spontaneous cure of the neurosis. This condition is very like that
of the ordinary compulsion neurosis; a ceremonial is devised, the
purpose of which is to ward off anxiety. Here the resemblance stops,
because in our case the ceremonial has a real basis and not, as it does
in the compulsion neurosis, a symbolic one. The ceremonial which
the patient unconsciously devises takes form some years after the
original traumatic event. Moreover, it is not completely efficacious;
the anxiety persists unabated. This ceremonial, therefore, has the
mechanism of a compulsory act; its purpose is unknown to the patient,
but it is used to ward off anxiety. Moreover, when the ceremonial is
analyzed, the anxiety appears to be displaceable, much like that in
the transference neurosis. This part of his neurosis is undoubtedly the
result of an old character disturbance.
We note, however, that the control of the patient over his body-
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 21
ego remains intact. The unconscious memories of the traumatic event
are capable of engendering anxiety, which is a much more highly
organized reaction to danger than the death faint or any other form
of complete lapse of consciousness. The conscious representability of
anxiety, when it is capable of being perceived as such, evidences,
therefore, a high degree of organization. As we shall subsequently
see, this anxiety does not entirely preclude the possibility of epilep-
toid reaction types but renders it much more unlikely. Sometimes the
barrier of anxiety is insufficient to stem the tide of the reaction, and
it proceeds to complete loss of consciousness.
These two types—the transference neurosis following trauma and
defensive tics and ceremonials—represent, therefore, the most highly
organized forms of response to the unconscious activity of the trau-
matic event. It may be well to mention here certain anomalies of
posture and gait assumed by soldiers, much to the amusement of
lookers on. Gaupp (12) records that these soldiers would walk with
the torso bent sharply forward, the upper extremities hanging limply
down. This is an unmistakable attitude of defense under fire. Others
walked ‘‘on all fours.”
AuToONomiIc DisTuRBANCES
The type of case in which autonomic disturbances constitute the
presenting symptom is extremely common in civilian life and is
frequently found in individuals who have been subjected to a series
of external hardships, shocks, fright, and so on. These cases were
particularly frequent during the war. In the fresh state they received
the name of “neurocirculatory asthenia,” “effort syndrome,” “sol-
diers’ heart,” “war neurasthenia.” Indeed, very likely a large num-
ber of the cases were described as Graves’ disease. Many of them,
prior to the use of basal metabolism as a criterion, were mistaken for
true Graves’ disease. It has recently been shown that a continuous
series of stages exists between those cases which are merely autonomic
disorders and true Graves’ disease, with all its characteristic symp-
toms and increase of basal metabolism. It has, moreover, been pos-
sible to observe patients passing from one to the other. Kessel and
Hyman have noted that a large number of these cases begin in civilian
22 THE TRAUMATIC NEUROSES OF WAR
life after a period of economic stress or shock, such as the news of
the death of a relative, a robbery, a business failure, and so forth. In
all these cases the usual physiological accompaniments of anxiety
persist long after the occasion which released them has ceased to op-
erate. They differ from the civilian neurasthenias only in that the
autonomic disturbances predominate.
In the acute stages vomiting, enuresis, diarrhea, and sweating were
common. One case I saw was a man with sweating from the left hip
down to the toes. His symptom, six years old when I saw it, yielded
to no treatment including hypnosis. In the acute stages occurred
dermographia, aerocyanosis, abnormal blushing and pallor, edema,
trophic changes in finger nails, dryness of hair, sudden grayness of
hair, and sudden falling of hair. Among the secretory disturbances
were anomalies of salivation and swelling of the parotid gland. Very
few of these latter carried over into the period of chronic illness.
Case 7. The patient had been injured six years previously when
buried by a shell. The symptoms of which he complained were gas-
tric disorders in the form of spasms, evidently pyloric and cardiac
spasms which occasioned vomiting. In addition he had the anxiety
dreams of sudden crashes and of houses falling, from which he, of
course, awakened with the customary terror.
Of chief interest in this case was the fact that, on external stimula-
tion, he developed a new phobia which seemed to have no connection
whatsoever with his traumatic experience. This occurred at the time
when the Yokohama earthquake was being described in the news-
papers. Ihe patient was seized with a fear that the same thing might
happen to New York. This fear obsessed him even at the time of
treatment. The relation of the fear to his trauma is, of course, quite
obvious,
This case shows that autonomic disturbances may coexist with dis-
placement phenomena.
Case 8. The patient, aged thirty, reported that his first symptoms
began in France. He stated that they began after he was struck by a
hand grenade, resulting in a wound in his right thigh. He was hos-
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 223
pitalized for five weeks and discharged without any permanent in-
jury. His service in the trenches was of rather long duration. An
unusually brave soldier, he received two citations. His first symptom
was a choking attack which, from his description, at first sounded like
a globus hystericus. But these choking attacks were not always in the
same location; at times they were rather high up in the esophagus,
at other times in the epigastric region. Stammering was one of his
chief symptoms. Prior to service he had a slight stammer, the origin
of which he could not remember but thought that under conditions
of stress he had been inclined to stammer ever since adolescence. Fol-
lowing his hospital residence the stammering became so intense that
he could hardly talk. Tremors of the hand were very pronounced,
becoming especially more marked on intention. There was a tachycar-
dia and an inclination to profuse sweating. Sexual power was much
diminished. Extremely irritable, sensitive to loud noises, and very
irascible, he flew into a temper at a slight provocation and suffered
from insomnia associated with dreams of exploding shells, falling
from high places, and so on.
As a result of these symptoms, the patient’s working efficiency was
greatly diminished. His prewar occupation was that of a tailor, and
since his release from service, he had been unable to hold a needle
in his hand. Having recently been married, he was much concerned
about his loss of efficiency. He had no prospects of being able to earn
a livelihood and was, for this reason, under considerable stress most
of the time. He began to show a diminishing interest in his environ-
ment and occasionally had spells of mild confusion, so that he did
not know where he was. His memory for recent events was poor. He
often found himself unable to recognize people on the street, al-
though they were his intimate friends. His face was constantly
flushed, his pulse rate varying between 120 and 140. Basal metab-
olism, determined several times, showed plus 1, plus 7, plus 9, and
on one occasion, plus 21. His thyroid was not enlarged. Most of the
symptoms, such as palpitation, sweating, tremors, vertigo, fatigabil-
ity, and irritability, were constant. The intermittent symptoms were
mildly confused states, smooth muscle crises in the form of pain,
belching, choking sensations, and occasional vomiting. These smooth
24 THE TRAUMATIC NEUROSES OF WAR
muscle crises were apparently aggravated by fright or excitement of
any kind.
The symptoms which caused him the greatest amount of distress
were the spasmodic phenomena, the tremors, the stammering and
the nightmares. Important to note is the absence of phobias. More-
over, the patient’s ability to perceive anxiety was decidedly limited.
He never complained of anxiousness or apprehensiveness, but he be-
haved as though constantly under the influence of fear. He was
uncommunicative, there being no urge to talk, inaccessible to sugges-
tion, and unresponsive to psychotherapy. He was somewhat improved
when given moderately large doses of atropine. An important feature
in this case was the fact that the traumatic experience reactivated a
former handicap, namely, his stammering.
Case 9. The patient was twenty-five years old. His symptoms were
of eight years’ duration. Until two years prior to examination the
patient was subject to frequent fainting spells. These fainting spells
began shortly after a hospital residence, but diminished in frequency
after discharge from service, and for the past few years had prac-
tically disappeared. His symptoms were headache and vertigo, hot
flushes, spots in front of the eyes, noises in his ears, violent anxiety
dreams from which he would awaken frightened, irritability, and
sensitivity to noises. More recently he had been subject to gastric
crises in the form of pain, pyloric spasms, nausea, vomiting, inability
to take food and occasional hemorrhages which proved on examina-
tion to be due to retching. He was sometimes unable to retain food
for days. His pulse was consistently rapid, varying from 120 to 150,
accompanied by weakness, palpitations, and occasional flushing.
The patient did not notice most of these symptoms until he re-
turned home. The only symptoms which troubled him prior to his
return were his fainting spells. During service he was long exposed
to trench warfare. On one occasion he was “blown up” by a shell and
remained unconscious for some time. Under hospitalization, he began
to have spells of unconsciousness. While in the hospital, he began to
note his irritability; previously of a very friendly and sociable dis-
position, he now became extremely cross to his superiors and refused
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 25
to put up with treatment. He deserted the hospital and returned to
his regiment, which we very clearly identified with his home. He
remembered having, when in line of duty again, none of the symp-
toms he had had while in the hospital, but they all returned after the
cessation of hostilities. This is another instance of how these symp-
toms are of some economic service during a period of stress. Their
continuation after this period into normal activities gives them the
character of symptoms.
The spells of which he complained were not accompanied by
anxiety and were not of long duration; though he lost consciousness
completely, he did not bite his tongue or relax his sphincters. The
dizziness of which he complained was not, apparently, connected with
any external stimulus or situation.
When originally seen, he was well nourished, his face flushed, his
eyes injected; his thyroid isthmus was considerably enlarged, but
the other two lobes were palpable as well. His heart was normal in
size; the pulse rate, 100 to 150. Blood pressure showed 100/70. He
had a negative Stellwag and a negative Von Graefe. There were fine
tremors of fingers, face, and tongue and profuse sweating of the hands
and armpits. He had a marked dermographia and a slight exophthal-
mus of the right eye.
On original examination it seemed possible that he might be a case
of hyperthyroidism. During the period of observation, over a year
and a half, the patient’s basal metabolism varied between minus 5
and plus 12. Therefore, this was evidently not a true Graves’ disease
but a general disturbance of the autonomic system, beginning with
his war experience. However, in view of his unilateral exophthalmus,
periods in which his basal metabolism was considerably increased were
not unlikely. The only medication to which the patient made any
response was atropine. This had some effect in slowing the heart
action and diminishing the sweating and the visceral crises.
He had no anxieties or phobias. His irritability was provoked easily
by obstacles encountered in the performance of routine activities and
in the presence of persistent noises. He had gradually become some-
what seclusive because he could not stand the strain of social rela-
tionships. The interesting features of this case were the persistence
26 THE TRAUMATIC NEUROSES OF WAR
of aggressiveness, irritability, and the typical nightmares and the dis-
appearance of his fainting spells which were unaccompanied by auras
with or without convulsions. The probability is that all the symptoms
of which he now complained were present on the battlefield. He took
no note of them there. They became particularly prominent after the
severe vertigo and fainting spells subsided.
Between this type of autonomic disturbance and true Graves’ dis-
ease lies every gradation. The true Graves’ disease differs only in that
the basal metabolism is much increased. Moreover it is likely (Kessel
and Hyman) that many cases of Graves’ disease have periods of nor-
mal basal metabolism. Theoretically, these cases of autonomic dis-
turbance are of great importance. They terminate either in true
Graves’ disease or in association with epileptoid phenomena. But I
have never seen a case which showed both increased metabolism and
epileptic phenomena. These cases are material for fruitful research;
apparently the rdle played by the thyroid and increased metabolism
has much to do with the reason for the absence of epileptic manifesta-
tions.” ,
Most authorities make no distinction between the autonomic and
neurasthenic types. I think it expedient, however, to do so, inasmuch
as each of these types represents a fixation on a different phase of the
adaptive process to danger. That a group of neurasthenic symptoms
is a pure fixation phenomenon is beyond question. The following
case is an instance.
Case ro. The patient was thirty years old, a British subject, and
had served in the Far Eastern campaign. Prior to service he was a
healthy individual and had had no neurasthenic symptoms at any
time in his life. During the campaign in the East he suffered untold
hardships, chiefly in the form of starvation and sleeplessness. Lack
of food and scarcity of men made it necessary for him to stay awake
thirty-six to forty-eight consecutive hours over a period of eight
months. During that time he had several illnesses which seem to have
*I regret that I could not further pursue this aspect of the problem. This case makes
me strongly suspect that the increased thyroid activity is a process which is absent en-
tirely in the epileptic reaction types. Graves
” disease and the epileptic reaction type seem
to stand at opposite poles.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 27
been some form of colitis. Since then the patient had had persistent
insomnia. He hardly obtained more than two hours sleep at night.
He was also troubled with vertigo, exhaustion, constant debilitating
feelings, anorexia, tremors, sweating, and frontal headaches.
The insomnia was apparently without content. No special thoughts
kept him awake. He was very reluctant to talk about his experience
in the East. Rarely did he have dreams; several which he brought
were repetitions of something he had actually done during the day.
Hypnotics had no effect.
In the acute stage exhaustive conditions were not infrequent.
Gaupp (12) noted acute cardiac disturbances—low tension pulse rate,
as low as forty per minute. Exhaustion and apathy were frequently
encountered, but these improved after a few days’ rest. The neuras-
thenic symptoms in the acute form were somewhat different from
those of peacetime, according to Gaupp. The hypochondriacal fea-
tures were much less emphasized during the war than after. This was
probably due to the fact that the war situation placed a good deal
more emphasis on the external dangers. Headaches, head pains of
various kinds, vertigo, and exhaustion and inapplicability to work,
poor memory, lack of interest in work, inability to concentrate, and
a hopeless and apathetic attitude were some of the important symp-
toms found with great frequency in these cases. It has, moreover,
been noted that the autonomic and neurasthenic pictures alternate
with each other, first the overstimulation, autonomic symptoms, then
the exhaustion phenomena. Most of these cases became well after
removal from the situation of war.
The temptation has ever been to explain all these symptoms on
the basis of internal secretory disorders. We cannot, however, regard
the neurasthenic picture in any way as a distinct type. The essential
symptoms of neurasthenia are present in almost every traumatic
neurosis. The subjective loss of interest in work, with its correspond-
ing effect on the moods of the individual, his feeling of being sick
and his lack of energy, the lowering of the threshold of stimulating
factors, the sensitivity to noise are not specific. Neither is the emphasis
on any special site, organ, or function specific. The hypochondriacal
preoccupations usurp the clinical picture as more severe symptoms
28 THE TRAUMATIC NEUROSES OF WAR
become present. Thus, Case 10 is a typical neurasthenia with a marked
hypochondria.
Case 11. The patient was aged twenty-nine. Sexually he was re-
tarded, “not interested,” “only interested in electricity.” Shy with
women, he had had no intercourse before service and only once or
twice after service. He had never had a love affair. Before entrance
into service the patient’s brother was killed in an accident in the sub-
way. This affected him to a considerable extent. He liked the army
life better than his previous civilian life. His health was always good
prior to service; he was strong, swam well, and was generally a good
athlete.
He reacted to service at the front fairly well. After repeated ex-
posure to shell fire and loss of sleep he became fearful. He was in
the artillery and used to go around without sleep for days. On one
occasion he was unrelieved for twenty-five days and under heavy
gun fire all the time. He was gassed mildly several times but was
never blown up or buried by a shell.
He could not tell whether he had had any symptoms while at the
front, but he had frightful dreams. After the armistice the following
symptoms presented themselves abruptly: headache, anorexia, in-
somnia, dizziness, faintness, irritability, crankiness—especially to
noise or argumentation, choking sensations in the throat with difficulty
in swallowing, profuse sweating, tremors, dyspnoea, rapid pulse, and
palpitation. Personality changes were decreased sociability and obses-
sion with his illness and his symptoms. When he came back, he fainted
several times; he had horrible dreams which continued constantly for
two or three years and after that occasionally up to the time he was
seen by me. Otherwise his symptoms were no different from those
he had before he returned from France. He was easily alarmed at
any accidents which he happened to see and became dizzy at the
slightest physical hurt.
The chief emphasis of this patient was on the exhaustion and the
hypochondriasis, This emphasis is not found in the autonomic cases.
The two types, however, have much in common and, as a rule, rep-
resent two phases of the same condition.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 29
SENSORY-MOTOR DISORDERS
In the acute stages sensory disturbances were extremely common,
usually in association with motor phenomena. The sensory dis-
turbances were frequent as accompaniments of wounds and injuries.
In these latter cases the distribution of the sensory disturbance dif-
fered very widely. In conjunction with localized wounds were fre-
quently found a general hyperalgesia, involving at times the entire
body surface. Eder (18) reports such a case in which the slightest
pinprick produced spasms amounting almost to convulsions. Anesthe-
sias and analgesias were extremely common, often being associated
with trophic skin disorders. The hyperalgesias as a rule resolved
themselves into hypalgesias. Of special note is the observation that
sensory disturbances were usually unilateral, involving the left side
in right-handed people and the right side in left-handed people. An-
other very common complaint in the acute stages was pain, localized
especially about the joints. These pains commonly accompanied
monoplegia of the flaccid atonic form (Binswanger).
All the special senses were subject to serious disturbances of func-
tion. Single and double amblyopia associated with photophobia and
pain. Hysterical amaurosis was observed to arise suddenly in soldiers
in whom the eye was a particularly aggressive weapon, such as sharp-
shooters. Partial and total night blindness have been recorded. The
commonest visual disturbance was the contraction of visual fields
amounting at times to almost tubular vision. Binswanger also records
central scotomata. These disturbances of vision were often associated
with blapharospasm and strabismus. Among the disturbances of hear-
ing were partial or complete deafness followed by pronounced hy-
peracusis; these were often associated with sensory disturbances of
the external ear. Disturbances of the sense of smell as well as the
sense of taste were occasionally observed. Also occasionally were cases
in which all five senses disappeared temporarily. In the chronic forms
most of the sensory disturbances persisted as a diminution of function.
In the skin hypesthesia and hypalgesia were the rule. The one note-
worthy exception to this was the ear, where hyperacusis was per-
sistently general. Of the disturbances of vision, contraction of the
visual fields was the most common in chronic cases.
BO. THE TRAUMATIC NEUROSES OF WAR
The motor disturbances involved almost every possible function
of the motor apparatus. In the acute stages perhaps the commonest
of all were tremors, many of which arose from the condition of stress
or shock and ran a comparatively short course. A large number, how-
ever, survived their hospital residences and attained a prolonged
chronicity. Even in these cases the tremors were intermittent. Accord-
ing to Binswanger, these tremors were capable of imitating almost
any organic condition; moreover they usually diminished on inten-
tional effort. Most of them were very fine in excursion. The tremors
of the hand sometimes attained a long chronicity. They were most
often one-sided, involving the working hand. These tremors were a
constant source of demand for vocational changes. Head tremors
were a good deal more frequent during the war than afterwards. In
the acute stages they showed themselves to be most refractory to
treatment. The same is true of the chronic forms. In this type of
tremor the patient usually had a weapon of great effectiveness in
exacting from the environment any demand he chose. These tremors
preserve in the chronic forms most of the characteristics they had in
the acute stage. The hand may remain useful for gross operations;
but for finer operations like shaving, buttoning a coat, or sewing, the
hand is completely incapacitated. |
Hysterical disturbances of gait were very common. Helpless con-
ditions which followed acute fright on the battlefield frequently gave
rise to local weakness of the lower extremities with dragging and
wobbling gait, sometimes to complete inability and incapacity for
locomotion. These disturbances rarely occurred alone but usually
appeared in conjunction with tremors and syncopal attacks. All va-
rieties were found from mild hysterical paraparesis to the most severe
forms, in which the patient could not get about without crutches.
Astasia-abasia was extremely common. Flaccid and atonic paralyses
in the form of spinal paraplegias were frequent but proved most
accessible to treatment. Monoplegias with contractures were also ob-
served. Monomuscular contractures, in the form of ptosis and con-
tractures of the platysma, were noted, and torticollis was not infre-
quent.
In the acute form speech disorders were extremely common. Most
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 31
of them, particularly the stammerers, were inclined to chronicity.
The aphonias and mutisms in the acute stage usually resolved under
treatment. Disorders of speech were most commonly associated with
deafness; Eder (78) says four out of ten. In the acute form mutism
was very frequent. These patients could, as a rule, write an accurate
account of their experiences. In this state patients cannot cough,
whistle, or make any sound when laughing and even have difficulty
in putting out the tongue. These patients can speak under anesthesia
or in sleep. Mutism may follow minor injury in some distant part
like a leg. Stammering usually followed mutism in the acute stages.
Case 12. In February, 1918, the patient was on a transatlantic
transport during some very rough weather. In the hold of the ship,
where the patient was on duty, were a great many unattached trunks
and boxes. Working in the hold was, therefore, a matter of con-
tinually dodging these objects as the ship pitched and rolled. The
patient evidently missed dodging one of the huge boxes and was
struck and squeezed between a big trunk and a bulkhead. He imme-
diately lost consciousness, and when he regained his senses, he found
himself in bed. Sensation and motion were entirely gone on the left
side of the body. He had remained in this same condition to the date
of examination, about seven and a half years after the traumatic
event.
When first seen, the patient had a spastic hemiparesis of the left
side, with contractures, and a typical glove anesthesia over this entire
side of the body, including the head. Reflexes were all present, how-
ever; Babinski was negative, and pupils were normal. The entire side
was subject to a trophic disturbance. Some atrophy was present from
disuse, beside the beginning of contractures which yielded readily to
passive movements. The patient was then able to use every muscle
in the upper extremity but did not have any of the kinesthetic sen-
sations which go with muscular activity. Through loss of deep muscle
sense, he could not determine weight and shape. Heavy weights in
the left hand would exert a pull at the shoulder, where he could
appreciate it. He could consciously direct movements of his upper
extremity.
32 THE TRAUMATIC NEUROSES OF WAR
These sensory disturbances remained unchanged. They extended
up to the shoulder and consisted of loss of pain and touch, but he
appreciated pain as pressure. He could not recognize objects by feel-
ing them. When he attempted action with the right hand, the left
was inactive; but when he tried to do anything with the left, his right
hand usually executed the movements the left could not.
The patient was treated by suggestive methods; hypnosis was
impossible. He refused absolutely to be hypnotized and had a re-
sistance to anything that would remind him of a loss of consciousness.
He refused to be anesthetized or to be given a few drops of chloro-
form in order to produce an artificial hypnosis. He was given sympto-
matic treatment for his contractures, and after several months of
physiotherapy he made considerable improvement. He had no return
of muscle sensation, however, or of sensibility, although, by dint of
sheer conscious effort, he was able to manipulate his upper and lower
extremities. This he did only on invitation, but what he could do
left the limb still useless.
Interesting to note is that the patient had none of the usual symp-
toms of traumatic neurosis. He had no disturbing dreams, no irritabil-
ity, no sensitivness to sudden stimuli, no secondary character changes.
His affect toward his disability was adequate, and he frequently
lapsed into depression because he made no progress with his cure.
One day the patient returned to the Clinic and stated that he was
perfectly well. Showing how he could use his upper and lower ex-
tremities with agility, he said that this had happened to him as a
result of having touched a relic. However, a month later his condi-
tion was as bad as it formerly had been.
Case 13. The patient, aged thirty-two, prior to service had stam-
mered slightly. The stammer became worse after one severe trauma
in the army. The patient was advancing with his company when a
shell burst about ten feet to the left of him. He was thrown down,
but not buried; became dazed, but not completely unconscious. When
he recovered consciousness, he found himself trembling violently,
and upon attempting to utter some words, he failed completely. The
patient’s older brother stated that, when the patient was five or six
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 33
years of age, he developed a stammer, either in imitation or through
the influence of a stammering playmate who lived in the same house.
Before service, however, the patient stammered only moderately.
The symptom had become much more severe since that time.
He had been noted to talk frequently in his sleep; he used foul
language fluently; he sang very well. Recently, while under the
influence of ether for an operation on his left lower extremity, it was
observed that he spoke with great fluency and swore at the surgeon.
In this case one must note a very common phenomenon. The
traumatic neurosis will revive a symptom that has long since been
dormant or aggravate one that already exists. Though it was impos-
sible in this case to investigate the origin of his original symptom, it
was probably not different from any case of stammering encountered
in civilian practice.
An important feature in this case is the absence of neurasthenic,
autonomic, epileptic, or displacement phenomena. The patient never
had any disturbing dreams and did not react violently to external
stimuli. Neither had he developed any of the secondary character
traits so common in traumatic neurosis.
Case 1 4. When originally seen, he complained of a strange symp-
tom from both lower extremities up to the umbilicus. The patient
was subject to feelings of numbness, pain, coldness, but more espe-
cially to sweating from the waistline down to the toes. This sweating,
he said, was continuous, especially at night. When asked how old
this symptom was, he said at least seven years. Among his other com-
plaints were such marked irritability and instability of temper that
he became aggressive and pugnacious very suddenly and without
sufficient cause. He also suffered from spells of transient blindness,
which lasted anywhere from five to fifteen minutes. Attacks of vertigo
was a significant symptom. His sleep was disturbed continually by
the usual dreams of drowning, being run over, receiving electric
shocks. In some of his dreams he was the aggressor.
When inquiries concerning his traumatic history were made, he
denied ever having suffered a serious shock. He casually stated that
he was on board the U.S.S. “President Lincoln” when she was tor-
34 THE TRAUMATIC NEUROSES OF WAR
pedoed. He was then asked to narrate in detail the facts of this acci-
dent, which were in substance: He was gambling in the kitchen with
several of the mess attendants when he heard a shot. This he inter-
preted as due to target practice and continued his game. Several
minutes later another shot occurred and then another, the last one a
distinct explosion. At this, all the men ran upstairs. The command
was given to take to the lifeboats. He then realized that the ship had
been torpedoed. It so happened that some of the lifeboats were dis-
abled and thus not enough to go around. At all events, the patient
and about eight other Negroes were obliged to take to the raft. He
described the sinking of the ship and his lack of trepidation at the
sight and his absence from panicky sensations. He said this was due to
the fact that the retreat to the lifeboats and rafts was very orderly
and that the ship did not sink until some hours later. At this point
the patient became rather excited and began to swear profusely. His
anger was roused, chiefly, by the incidents connected with the rescue.
They were in the water for a period of about twelve hours when a
torpedo-boat destroyer picked them up. Of course priority was given
to the officers in the lifeboats. The eight or nine men clinging to the
raft were allowed to remain in the water and had to wait for six or
seven hours longer until help came. In describing his feelings while
in the water, the patient emphatically denied having had any panic
or fear. However, it was quite clear to the writer that, while narrat-
ing these incidents, he was very much disturbed. The disturbance
he acknowledged. He said that telling the story made him fearful.
I made him revive many details of the story which had a harrowing
effect on him. |
The similarities between the symptoms of which he complained,
in the form of sensations and sweating from the waistline down, and
his story of being submerged in cold water from this point of the
body to his lower extremities, were pointed out to him. He admitted
that, when he allowed himself to close his eyes and think of his pres-
ent sensations, he still imagined himself clinging to the raft, half
submerged 1 in the sea, Thereupon the patient stated that while ebinig-
ing to the raft, his sensations were extremely painful ones and that
he thought of nothing else during the time. He also recalled the
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 35
fact that several of the men had lost consciousness thus and were
drowned. To a large extent, the patient obviously owed his life to
his concentration on these painful sensations occasioned by the cold
water. I'he symptom represented, hence, an hallucinatory reproduc-
tion of the original sensations of being submerged in the water.
Concerning his remaining symptoms, it is of interest to note that
he developed many of the secondary symptoms of traumatic cases
which are epileptoid in character. The spells of transient blindness
used to come on specific occasions—when he saw something in the
nature of violence. Thus the patient was once walking on the road,
and at the approach to a railroad crossing he witnessed an automobile
colliding with a train. He became maddened with excitement, was
blinded for ten minutes and was taken home in a state of extreme
agitation. He alleged that it took him four months to recover from
the effects of this incident, although the danger did not directly con-
cern him. During these four months he was obsessed by the vision
of the accident. He had, in fact, a profound reaction to violence of
any kind and could not witness others being injured, hurt, or threat-
ened. Prior to his service he never had fears or phobias. An employee
of a railroad company prior to the war, he had seen a very serious
railroad wreck without injurious consequence to his state of mind.
In fact, he himself had assisted in extricating people from the wreck.
He was also extremely sensitive to loud noises. This is remarkable
because the patient heard very little shellfire during his naval career,
yet he shared with patients who had come from the zone of active
fighting this secondary reaction. He would yell and scream on a sud-
den call or other abrupt noise and was subsequently troubled by the
violence of his reactions to these stimuli. He claimed that he felt like
suddenly striking people and that he had become very pugnacious
toward his family. He remarked, “I wish I were dead; I make every-
body around me suffer.”
The dream life of this patient consisted of the usual disturbing
dreams, but recently his memory for them had been poor. However,
he would start from his sleep several times during the night.
Of great interest is the fact that the patient had no sensory dis-
turbance whatsoever in the lower extremities; however, he protected
36 THE TRAUMATIC NEUROSES OF WAR
them most tenderly with all kinds of ointments and with warm stock-
ings in all temperatures. His reactions to water were quite typical.
He did not like sea-bathing, and after his return from service, when-
ever he had attempted to go into the water, he had always become
nauseated and vomited. Now he was avoiding sea-bathing.
The conditions in the sensory motor group which tend toward
chronicity are the spastic paralyses which usually develop contrac-
tures, the course and fine tremors, the sensory hypochondriacal fixa-
tions, the stammering, and the functional exaggeration of somatic
injuries, especially in the region of wounds. Enuresis persisted in
only a few cases. The vasomotor secretory disturbances in the form
of sweating often attain a chronicity in most annoying forms. Thus
one patient had a unilateral sweating, involving first the entire right
side of the body, then only the region from the waistline down. This
was unaccompanied by the usual dream life and irritability.
Tue Epiteptic SyMPTOM COMPLEX
In the acute stages a great many of the war neuroses were noted
to have paroxysmal, recurrent symptomatology. The commonest
forms were mild syncopal attacks, sometimes breaking out abruptly,
but more often after a brief period of prodromal symptoms, such as
nausea, weakness, and “blackness before the eyes.” The preéminent
symptom was an unconscious state with flaccid limbs, closed eyes, and
complete loss of consciousness. During the attack the face was pale,
respiration superficial, and pulse slow. Patients were impervious to
external stimuli and insensitive to pain; at times the eyelids fluttered.
The eyeballs were mobile and on forcible opening were usually rolled
outward and upward. These spells, lasting anywhere from minutes
to hours, would overtake the patient in the midst of activities and
most frequently after exertion or effort. The spells corresponded in
every way to the hysterical syncope noted in peacetime. However,
during the war they were exceedingly frequent, and their content, as
judged by the dream life and the secondary reactions, had really no
resemblance to the hysterical attacks of peacetime. This condition
was very frequent during active warfare, particularly during forced
marches and active campaigns, but was not altogether unknown be-
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 37
hind the lines. Soldiers who were once subject to these attacks and
were then sent back to the lines most often had recurrences of the
attacks when reassuming their former line duties. A most interesting
feature of these conditions is, according to Binswanger, their occur-
rence in the form of epidemics in hospitals. In other words, they were
very easily imitated. Once this reaction was initiated, such patients
would resort to it in the face of any frustration. The attacks never
occurred at the beginning of a furlough, but very frequently at the
end. This type of soldier was absolutely lost as regards his capacity
for further service.
Besides this form was a group of hysterical lethargic states in which
the paroxysmal changes in consciousness took the form of a profound,
stuporous sleep. These patients would gradually stop their activities
and fall to the floor in a deep, narcoleptic sleep. This could be differ-
entiated easily from natural sleep by the response to external stimuli.
The more common twilight states occurred in their simplest form
as abrupt changes from the state of sleep to a somnambulistic trance.
They were, to all intents, fully enacted dreams. The patients would
live through their war scenes very vividly while in these trances.
Every detail of warfare was reéxperienced, accompanied by the ap-
propriate mimicry and at times intermingled with reminiscences of
their former lives.
Another form of twilight state occurred abruptly during the wak-
ing state, usually in a form similar to that of the nocturnal twilight
states and with active hallucinatory experiences and mimicry. On
these latter occasions the relationship with the external world was
completely severed. Sensory stimuli on the skin and verbal sugges-
tion had no effect. The attack gradually wore itself out. In a few
cases, some contact with the external environment appeared to exist,
except that the patients mistook situations and called individuals by
wrong names. The sick chamber was often represented in hallucina-
tions by a burning castle or a chateau surrounded by soldiers. Many
of these hysterical deliriums were, to a certain extent, amenable to
influence. The amnesia for these episodes was, as a rule, complete,
though they could sometimes be recalled as dreams. These patients
were amnestic for their war experiences, sometimes for only individ-
38 THE TRAUMATIC NEUROSES OF WAR
ual episodes, sometimes for an entire war period, and occasionally
even for long periods prior to entrance into service. [his amnesia
was usually persistent. During these episodes cataleptic states in-
volving the entire body or parts of it were encountered. These cata-
leptic states were sometimes of a complete rigidity and sometimes of
a waxy flexibility.
Finally, there was a group of true convulsive states with very deep
disturbances of consciousness, following immediately on an acute
shock or an exciting experience. In many of these attacks, instead of a
convulsion, wild gesticulations of the limbs, spasmodic stamping of
the feet, and crying were its substitutes. Also, a partial tetany of all the
limbs was noted.
The immediate reactions to shock or fright deserve our attention,
particularly because of the sequelae we see in the chronic cases. In the
first place is the reaction to fright or shock, known in peacetime, but
not called pathological, since it leads to no permanent fixation. This
consists of pallor, trembling, stiffening of the body; inability to speak
or move the limbs; disturbance of cardiac rhythm, of the pulse, and
of blood pressure; gastric and intestinal disorders; vomiting and
diarrhea; changes in the respiratory activities, in the sweat glands,
urinary bladder, and gastric juices; diminution in blood supply to
the various organs; and dimming of consciousness even to exhaus-
tion and inability to think sequentially. In these phenomena we are
still within the limits of normal biological reactions to shocking ex-
ternal stimuli of body and mind. Such reactions are, as a rule, tem-
porary, or else they give rise to death through paralysis of the vagus.
This latter result, however, is very rare.
In the pathological cases and in those having a tendency to fixate
upon the trauma, the effects are much deeper and much more lasting.
For the frequence of these conditions during the war, the persistent
trench warfare with its dull expectancy and its weapons of unprece-
dented power is undoubtedly to blame. When the reaction to shock
and fright persisted instead of disappearing, as is normal when a
condition of safety is attained, these conditions acquired a certain
amount of psychological elaboration after the patient was out of
danger. In most of the chronic cases observed, the symptoms first
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 39
took shape in the hospitals rather than on the battlefields. Some
authors, I feel, have emphasized too much the acquisition of these
symptoms in hospitals as a result of suggestion, that is, from seeing
other patients in the same condition. This cannot be so, for we ob-
serve in almost every persistent case of this type that the disease is
kept alive eight years or more after the traumatic event, by a very
distinct dynamic group of forces which no suggestive power can simu-
late. Furthermore, we find in the symptoms themselves, parts of the
original traumatic experience attached to or a part of the symptom
itself. The fact that symptoms of a traumatic neurosis make their
appearance some time after the traumatic experience can be verified
in every case. On this account the reference to the contagiousness of
the disease in hospital wards is somewhat exaggerated.
In the acute stages many of these shock cases were accompanied
by unilateral motor symptoms, either paralyses or sensory or secre-
tory disturbances, such as hemiplegias, hemitremors, hemianesthesias,
or deafness on one side. This was also the case with the vasomotor
and secretory disturbances. In fact, the more closely a symptom ad-
hered to the autonomic classification, the more likely it was to be
unilateral. Differences in the size of pupils, unilateral sweating, der-
mographia, unilateral grayness of the hair, and so on, were of fre-
quent occurrence.
Many of the acute reactions to shock terminated in what may be
termed “shock psychosis.” Upon being picked up immediately after
the shock and placed in hospitals, many of these soldiers had initial
anxious deliriums, during which everything in the environment was
regarded as hostile and anybody who approached excited violent fear
reactions. Wild motor activity with mutism, depression, and dis-
turbances of sleep sometimes followed.
Perhaps the most common form of this psychosis was the acute,
passive, negativistic stupor with mutism, complete immobility, total
anesthesia with inability to take food, incontinence, total unconscious-
ness at first and later cloudy states, and inability to stand or to walk.
Gradually these patients had to relearn sphincter control and enuncia-
tion of words—at first saying only “yes” and “no” and then answer-
ing to their names. Very gradually they were taught how to grasp
40 THE TRAUMATIC NEUROSES OF WAR
objects and how to feed themselves. Familiarity with the environment
was also regained slowly; some time elapsed before the patient began
to take an interest in his destiny. Of interest is the fact that most of
these patients were able to recall the traumatic event; they remem-
bered some details of their behavior such as making certain efforts
to save themselves just before consciousness disappeared. Gaupp
quoted a case without recollection of the traumatic circumstances
beyond the optical and acoustic accompaniments of the exploding
shell which caused him to lose consciousness. This latter observation
is important because the psychic experience—the feelings and ideas
excited by the explosion—called forth the powerful action of the
entire organism, that is, unconsciousness and other symptoms of
fright, as a defense against it. Gaupp believes that, between the
moment of the explosion and the following psychic disturbance, an
interval exists during which the perception of the effects of the
explosion, the sight of mutilated comrades, the excitation of fright,
aggravate the reaction to the trauma (12).
Often these cases of fright stupor were not always passive and
without feeling. Very frequently the patients in their stupor shouted:
“The enemy is coming!”; “They are coming!”; “Get ’em!”; “Fight
2em!”
In addition to these stuporous states and hypochondriacal anxieties
are a great many delirious states, dimmings of consciousness, dream-
like periods, complete disorientations of time and place. A queer form
of behavior resulting from acute shock conditions was one in which the
delirium took on a strange infantile character, in which the individual
spoke ungrammatically, played with toys, clung to his sister’s coat
tails, mistook things in his environment as a child does. This type of
behavior often gave the impression of simulation. These patients
would answer: “Two times two are five;” “The sky is red;” “Grass
is blue;” The examining doctor was his mother, Fantastic confabula-
tions were also in this type of case. Some authorities see in this a
pseudomanic picture. In some cases the deliriums were like manic
excitements, and the patients had to be confined in padded cells or
strait jackets for long periods,
Most of these acute cases recovered. A large number, however,
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 41
remained chronic in forms such as we have described under the
autonomic disturbances. The more severe forms will be described
below.
The term “epileptic symptom complex” is designated to describe
a syndrome of frequent occurrence in the chronic forms of traumatic
neurosis. [his particular wording was first used by Stekel in connec-
tion with cases which clinically presented symptoms of essential
epilepsy. I do not intend to convey, by the use of this term, that these —
cases are true epilepsies. They correspond more to what has hitherto
been described in literature as “affect epilepsy,” “reflex epilepsy,” or
periodic recurrent disturbances of consciousness. I believe that this
symptom complex is very closely related to what occurs in other cases
as pure forms of severe vertigo. The epileptic symptom complex may
be found in cases which show, clinically, no resemblance whatever to
epilepsy and in others which can hardly be differentiated from them.
All these fluctuations and variations of symptoms seem to be differ-
ences in quantitative reaction rather than differences in kind.
A most frequent complaint among veterans six or seven years after
return from war is the continuance of periodic disturbances of con-
sciousness. This takes either the form of severe headaches and intense
vertigo, sometimes so severe as to lapse into unconsciousness; twilight
states, periods of dazedness, confusion; various somatic and peripheral
paresthesias; or else complete loss of consciousness, with or without
convulsions. In not a few cases one finds these twilight states ac-
companied by special modes of behavior before, during, or after the
disturbance of consciousness. Thus patients will describe attacks that
come on specific external provocation. Others occur with specific
forms of aura; others, not initiated by auras of any kind, show instead
of the typical convulsions, outbursts of violence, in which the patients
break and tear objects around them or assault people. The convulsive
states may or may not have biting of the tongue and relaxation of the
sphincters. In addition to this central complaint, one often finds
insomnia associated with the typical dreams of the traumatic neurotic,
a symptom which continues unchanged despite the many years of
removal from the seat of danger. A series of secondary defense re-
actions in the form of irritability to auditory stimuli or other specific
42 THE TRAUMATIC NEUROSES OF WAR
sensory irritability also exists as an evidence of a severe sadomasochis-
tic conflict manifesting itself in extreme variations of temper, from
undue tenderness to outbursts of cruelty and violence. In these latter
cases is a variable amount of displacement, usually in proportion to
the amount of anxiety. As a rule, these anxieties are devoid of content.
That is, the patient does not fear a state of being or a situation; he is
more prone to fixate his complaints on somatic or physiological ac-
companiments of fear. The variations in quality seem to depend
chiefly on the degree of disorganization and are in part determined
by the reaction to the orginal traumatic event. The whole epileptic
symptom complex appears to be in the nature of a repetition phenom-
enon. The following case shows the mildest form in which the
epileptic symptom complex may exist.
Case 15. The patient was thirty-two years old. He seemed always
to have been a normal individual prior to service, well adapted in his
sex life and social activities, and had apparently a normal attitude
toward work. He was examined in a routine manner and did not
regard his complaints as meriting the attention of a physician. He
complained of periodic attacks of faintness, a dazed, numb sensation
“as if all the blood in his body had stopped circulating.” He also had
a sensation of numbness, tightness and tingling about the mouth, a
feeling of weakness, and a sinking sensation in the epigastrium. He
never lost consciousness but felt dazed for a few minutes. After this
was over, he was usually overtaken with intense panic; sometimes
this panic came upon him without his feeling dazed, especially when
he rode in the subway and the train happened to stop midway between
stations. He had great difficulty in falling asleep and was usually
aroused in a panicky condition just as he was about to fall asleep. This
might occur as often as six or seven times a night. Frequently he was
awakened from sleep by typical war dreams or other dreams of
disasters about to overtake him. He was sensitive to noise and inclined
to be alternately cruel and intolerant and extremely tender. These
fluctuations of temper were unknown to him prior to service. The only
trauma he suffered was that of being mildly overcome by gas. The
sensations of panic and the tingling sensations about the mouth and
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 43
epigastrium he readily identified as the sensations he had had on the
battlefield immediately before he lost consciousness from gassing. He
thought, moreover, that his present episodic attacks were much more
severe than the ones he originally had while on the battlefield.
This was a mild case persisting eight years after service in a person
who had been fairly well adapted and who was so at the time of
examination. If he had not been ordered, in a routine manner, to be
examined, he would never have applied for medical help. I regard
this type as being fundamentally of the same nature as the most
severe cases, those which cannot be differentiated from essential
epilepsy.
This series of cases shows certain characteristics by which we can
judge the severity of the case, the depth of internal disorganizations,
and the prognosis. Many of the cases manifest the same constant
picture; the spells of unconsciousness are provoked chiefly by external
factors which prove under close examination to be exactly the same
factors causing the original loss of consciousness on the battlefield. In
short, we have here a typical “conditioned reflex.” It differs, however,
in one important respect: conditioned reflexes are learned. Moreover
the affective accompaniments of this reaction are different from those
associated with conditioned reflexes. In another group of cases, the
provocation is endogenous or endopsychic, and its connection with the
original trauma is indicated only by a hallucinatory reproduction of
some circumstances originally associated with the trauma. This has,
in every way, the structure and the function of an aura.
A second distinguishing feature is the variable amount of anxiety
which is perceived as such, displaced or utilized in connection with
the attack. We find that this anxiety is really the nuclear phenomenon
of the entire syndrome and that the more readily the anxiety is
uttlized in the form of displacement or incorporated into the attack
in some way, the less does the disease take on the characteristics of
essential epilepsy. In other words, when the anxiety is displaced, the
condition has less resemblance to epilepsy; when the anxiety 1s lack-
ing, completely repressed and in its place a group of defense mecha-
nisms in the form of rigid tension states, the function of which seems
to be to prevent the anxiety from becoming conscious in any form, the
44 THE TRAUMATIC NEUROSES OF WAR
resemblance to epilepsy is greater. The factors releasing the individ-
ual attacks may be of either external or psychic origin. Among the
former the commonest is unanticipated noise and undue physical
effort. The intrapsychic factors cannot be identified except by the
traces left in the form of an aura.
Concerning the seizures released by external factors, we find that
this sensitivity to release by noise or effort is merely an exaggera-
tion of the characteristic found in all traumatic cases, namely, the
generalized irritability and intolerance of effort. Instances of this type
are too common to note, but perhaps the following will indicate how
severe the reaction can be. A patient of about thirty years of age came
for a routine examination and warned me, before I began, to be sure
that I made no sudden noises; that, if he were to hear a sudden noise,
he would not be responsible for his actions. He then proceeded to tell
me that on several occasions as he was walking on the street, a passing
automobile gave rise either to some backfire or a “blowout.” The
patient stated that he immediately lost consciousness, but during this
state of unconsciousness he attacked the nearest passer-by and began
to strangle him. On another such occasion he assaulted a traffic police-
man and the latter, in order to protect himself, had to club the patient
and bring him to the police station. He was released when his condi-
tion was investigated.
Whereas many of these cases at first react violently to noise, the
older the neurosis grows, the less likely are they to respond violently
to this stimulus. As a rule, the older it becomes, the more likely must
the stimulus be something very specific, something directly associated
with the traumatic experience.
Case 16. The following case is an interesting example of the repeti-
tive mechanism provoked by external stimulus.
The patient was twenty-seven years old when first seen, his
neurosis, six years in duration. He gave no history of neurotic traits
in childhood. The disability from an attack of rheumatism while he
was in training in this country was not serious enough to prevent his
continuing military duties. While on duty he was with a detachment
which took possession of a shack one night and was obliged to spend
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 45
the night there. He woke up in the morning and found that the
entire company had been gassed while sleeping, several very severely.
He himself escaped with a mild gassing. After hospitalization for six
weeks he returned to his battalion. By that time hostilities had ceased,
and in several months he came back to the United States. On a few
occasions during this interval—the cessation of hostilities and the
embarking for this country—the patient remembered getting the
spells from which he now suffered.
The spells were described by him as follows: On certain occasions
he would become violently flushed, his heart would beat rapidly, he
would become dizzy, would vomit, and then lose consciousness. His
loss of consciousness usually lasted from one half to one hour. He
noticed that these attacks always followed exposure to certain odors,
from volatile oils; thus an attack could be set off by perfume, lemon
oil, banana oil, ether, chloroform, and so on. He also remarked that
certain odors, such as musk, were offensive to him. Volunteering all
this information, he came to the conclusion in the following way. At
first, he said, the spells overtook him without any particular provoca-
tion. He was employed in a butcher shop frequented by fashionable
women. Many of them came heavily perfumed. When they would
enter the butcher shop to place an order, the patient would become
dizzy and begin to vomit. Often being able to inhibit the symptoms
at some stage, he would not always go through the entire spell to
unconsciousness. However, his reactions interfered with his occupa-
tion so much that he asked for help.
He was then asked to recall his symptoms on that morning when he
awoke in the shack and discovered that he had been gassed. He re-
called a similarity to those which he now had on the stimulus of
perfume; in fact, he remembered that what weakened him was the
nausea, the vomiting, and the giddy feeling. In short, the flushing, the
rapid pulse, the dizziness, and the vomiting were a repetition of the
original traumatic event which overtook him in his sleep. The stimu-
lus was always exogenous.
In addition to these symptoms, the patient had the usual secondary
defense mechanisms of the traumatic neurosis in the forms of irri-
tability, restlessness, ill humor, aggressiveness, and so forth. Five
46 THE TRAUMATIC NEUROSES OF WAR
years after the war had ceased, his dreams were also the typical
dreams of the war neurotic. Their content took the usual form—being
killed either by means of weapons, drowning, falling off buildings,
and so on. Naturally his sleep was very much disturbed. His physical
examination was negative, and no symptoms of a constant disturbance
of the autonomic system were found.
That the patient was asleep when gassed is an important feature.
It emphasizes the unawareness of the stimulus; and the awakening to
find himself unprotected had much to do with the original traumatic
impression.
The following case is of special interest because it illustrates the
remarkable specificity with which the repetition mechanism manifests
itself and the photographic manner in which it reproduces the original
trauma.
Case 17. The patient was twenty-seven years old, a Negro of
limited intelligence. He was accustomed to unskilled labor prior to
service. Very little of his past history could be ascertained beyond the
usual diseases of childhood. As is usual in his race, there existed
neither a history of neurotic traits nor any history of venereal disease.
The patient made only one complaint, “spells.” He described them
as follows. They began with a feeling of itching in his face; this would
last several minutes. “It feels like pins and needles. I get ‘blown,’ and
then I become unconscious. Whenever I come out of the spell, my
face is always swollen and scratched. The funny thing is that I only
get these spell when it rains. I never get a spell when I am in the
house; always when I am out-of-doors. I am terribly afraid of the
rain. | am not afraid to take a bath, and I am not afraid of water, but
I am afraid of the rain.” The patient stated that in former years he
used to get his spells whenever he was frightened or whenever he
would hear loud noises; but of recent years he had them only in the
rain; in fact, they occurred only when he became drenched or when
his feet got wet. The aura described as itching of the face was present
on every occasion when he lost consciousness.
From the history of these spells, this was obviously a repetition
phenomenon. He was, accordingly, asked to describe the loss of
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 47
consciousness which he originally had on the battlefield. The patient
had at that time a partial amnesia for the events of the morning of
September 26, 1918, when the traumatic event took place. It was a
very stormy day, and he was in a company charging a position along
a river. He remembered rushing forward in the violent rain and
being drenched through to the skin. He also remembered the sensa-
tion of the rain beating down on his face. He recalled having passed
through two towns and also having received a head wound which,
however, did not cause him to lose consciousness or to retreat. He
continued, notwithstanding his wound. Although it had penetrated
his helmet, the wound was evidently very superficial. At the time he
was Wearing a gas mask which was leaking. The point at which his
memory grew dim was the race down a steep incline and his falling
to the ground.
Aside from the small scalp wound, the patient received no other in-
jury. He woke up in a hospital several days later. It is reasonable to
suppose, therefore, that, due to the violent storm and the patient’s
falling to the ground in an unconscious state, he must have been ex-
posed to the rain for a long time and to the sensation of water’s beat-
ing upon his face and perhaps to fragments of dirt and sand. More-
over, his face was also burned by the mustard gas.
The neurotic reproduction was, therefore, photographic. The itch-
ing of the face was undoubtedly a reproduction of the sensation of the
splashing of mud upon his raw skin and the burning of the mustard
gas. The scratching executed in his trance was again the effort to
remove the offending stimulus.
The patient likewise emphasized the change in his character from
normal behavior reactions to violent tantrums, a tendency to aggres-
siveness and irritability, and the feeling of great commiseration when
anybody was exposed to danger. When he saw a child either injured
or “almost injured,” he became completely unnerved and had to go
somewhere for a drink to brace himself. During the time of observa-
tion, the patient happened to be out one Sunday when it began to rain.
He had a tendency to forget that his spells would come when it
rained, Interesting to note is that he did not always protect himself
against the rain. On this occasion his feet became wet, and a spell
48 THE TRAUMATIC NEUROSES OF WAR
ensued, thus accurately repeating the phenomena as above described.
The patient was sometimes able either to control the spell or inhibit
it. He suffered from feelings of anxiety, panic, and helpessness just
prior to the spell, but in the intervals he had no such symptoms. I
never observed the patient in one of his spells nor the special char-
acter of them.
A- remarkable feature of this case was the nonprojection of his
phobia. In his neurosis, so different from the ordinary transference
neurosis which erects many defensive barriers before the dreaded
situation, this patient really did not “know enough to get in out of the
rain.” He did not feel compelled to carry umbrellas, rubber shoes,
or raincoat. Moreover, one must remark the inadequacy of anxiety as
a protection altogether, since it preceded every attack but had no
influence in arresting it.
Case 18. The patient, of meager education, was twenty-six years
old. The only thing noteworthy in his past history was his not being
a neurotic individual. He was sociable, a steady worker, and always
healthy. He married young, was much attached to his wife, and had
two children of whom he seemed to have been very fond. His previ-
ous sexual development appeared to have no bearing on his present
difficulties. He was a volunteer in the army and served two complete
enlistments with good records. During the war he participated in the
Saint-Mihiel drive. There he was gassed and sustained a slight
shrapnel wound which was taken care of at a dressing station.
The symptoms of which he now complained had persisted unabated
for seven years after his original injury, despite repeated attempts at
treatment. The symptoms were as follows: He was subject to dizzy
spells, periods of confusion, occasional fainting spells, and shortness
of breath. The patient’s greatest complaint was, however, the loss of
his former evenness of temper and gentle disposition. He stated that
he would lose control of his temper easily, pick quarrels on the
slightest provocation, was threatening and abusive upon small cause,
got into arguments, was very irritable, and reacted violently to any
environmental physical pain or stimulus which annoyed him. His
symptoms had interfered with his efficiency and comfort to a marked
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 49
extent. He had also had dreams frequently. Their content was: a)
that dead people were speaking to him; b) that he was either attack-
ing or being attacked; c) that he was falling; d) that he was drown-
ing; e) that he was being run over by trains; f) that he was being
bitten by snakes, and so on.
The patient stated that during the past seven years certain changes
had taken place in his symptoms. Whereas he was formerly subject
to frequent fainting spells, these were now almost entirely displaced
by attacks of vertigo. Formerly the attacks of vertigo always preceded
the spells of unconsciousness. In other words, the dizziness of which
he now complained had been, heretofore, the aura of his fainting
spells. It now became his chief symptom. The patient spontaneously
realized that these spells of vertigo were frequently precipitated,
though not always, by certain stimuli in the environment. Again, they
bore a very striking resemblance to the occasion on which he orig-
inally lost consciousness in battle, namely, volatile odors; ether,
chloroform, and gasoline used to provoke either dizziness or faintness.
Thus the patient had to give up positions in which he was exposed to
irritating odors. He took work as a starter for a taxicab company but
gave it up because of his standing near a group of automobiles which
continually exuded gasoline odors. Loud noises did not seem to
provoke his attacks; but continuous stimuli of any kind, sometimes
in the shape of persistent noises, made him irritable and aggressive.
It was quite natural, in this case, to find that the patient had been
gassed on the battlefield in the following way. He was in a gas bar-
rage, and his mask evidently had a leak. He remembered feeling, at
first, rapid pulse and then dizziness; then everything became dark,
and unconsciousness ensued. He awoke in the hospital after an un-
conscionable time. An important fact in this case was that the patient
did not stress the attacks of vertigo and fainting as the main symptoms.
What most distressed him was his irritability and his aggressive
tendencies. He stated: “I now have a very bad temper, and I will tell
you what I am accustomed to doing. Once while working, the foreman
said something to me; I got into an argument with him and picked
up a crowbar and went after him. I dropped the bar, but I used my
fists, so that I knocked him unconscious; and I ran away and never
50 THE TRAUMATIC NEUROSES OF WAR
came back.” The patient, deploring his state of mind profoundly, said
that he feared he might kill somebody in one of these fits of anger
when he really did not desire it.
The repetition mechanism was easily understood by the patient,
although after several months’ treatment the spells of dizziness still
occurred. However, the dreams which used to disturb his sleep ceased
almost entirely. No changes were effected in his temper. He was still
irascible and violent. He was able to work steadily for some time,
however. He had no anxieties, no conscious representations of fear,
and practically no transference symptoms.
The case also illustrates an important fact, that the unconsciousness
may be replaced by one of its prodromal symptoms, the aura. In other
words the spell is inhibited at the aura. This is seen only in chronic
cases and usually goes with improvement in the patient’s condition.
The second point of orientation in this group of cases is the presence
of and disposition to anxiety. The anxiety problem, from a clinical
point of view, has an important bearing on the prognosis and therapy
of the case. The manifestations of anxiety vary widely. Very few of
‘these cases complain of phobias, and even when they do, the phobia
never has the organization or the elaborate ramifications it has in the
transference neuroses. As a rule, the patients are subject to vague
unmotivated anxieties, and one usually hears great emphasis placed
on the somatic accompaniments. It appears erroneous to call this state
one of anxiety; it is much more a state of defense and expectancy, in
which much of the emphasis goes to create adequate defense against
its emergence. Neurotic phobias, such as those encountered in trans-
ference neuroses, are absent. I can recall only about three cases of a
very large number who feared epilepsy, insanity, or heart disease. Of
these phobias, claustrophobia was the most common; but, as a rule,
the claustrophobia was more in the nature of a conditioned response
then a displacement symbol. I have noted earlier in the chapter a case
in which the patient had a phobia that New York would be visited by
an earthquake. ‘[’his was not so much a symbol of his traumatic experi-
ence as his direct fear of a recurrence: he was buried in a trench. This
particular type of anxiety in a displaceable form is rare among patients
showing the epileptic symptom complex.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES | 51
A not infrequent form which the anxiety takes is the fear of the
unconscious spell itself, a fear similar to those encountered among the
“A ktualneurosen” of peacetime. The only connotation of the fear is a
dread of impending death. Occasionally some of these patients dis-
place their anxiety in the form of a fear of high places. Many of them
have anxieties after their seizures. The anxieties, on these occasions,
most frequently concern the seizure itself, a dreaded recurrence, and
include the fear of leaving the house lest an attack overtake them in
an unprotected place.
A convenient place to look for the evidence of anxiety, in these
cases, is in their dream life. All of them, excepting only those in whom
the clinical pictures cannot be differentiated from essential epilepsy,
have the typical dreams of the traumatic neurotic, in which they are
being annihilated in one way or another and from which they awaken
in terror. In cases which resemble epilepsy clinically, one usually
elicits a history of having had such dreams over a long period of time,
but of the dreams’ having since ceased. Others will say that, whereas
they have dreams of this type, they no longer awaken from such
dreams, Asa rule, patients subject to these horrible nightmares have
some representations of the anxiety in their waking life. The anxiety
can usually be revived. When these dreams have completely ceased,
the patient shows an apathy to his spells of unconsciousness and a
lack of interest in his rehabilitation and cure, which is equaled only by
the true epileptic. The disposition of the anxiety is an important
theoretical consideration to which we shall return again.
In this group of cases lies one further point of differentiation. Some
patients, in their unconscious state, relive their traumatic experiences;
others have the typical kind of tonic and clonic convulsions seen in
essential epilepsy. The following case is of interest because it shows
one of the types of traumatic neurosis allied to epilepsy. It manifests
in a very marked manner the fear of the environment, the sado-
masochistic conflict, the presence of intense anxiety during spells, and
the fact that anxieties may at times entirely displace the spells of
unconsciousness.
The patient reveals this type with aura, anxieties, displacements,
and ability to transfer repressed anxiety.
52 THE TRAUMATIC NEUROSES OF WAR
Case 19. The patient, first seen in March, 1924, was thirty-six
years old, and was born in the United States. He stated that prior to
the onset of his present illness he had never had a nervous symptom.
He was brought up ina rural environment and was an active individ-
ual. Before service he had become connected with the motion picture
business as director for a small firm. During service he was a private.
He once suffered concussion by a shell and spent six months in the
hospital.
His chief complaint was unconscious spells at intervals varying
from one month to three or four. Their onset was not abrupt; in fact,
loss of consciousness was always gradual, usually accompanied by an
aura which the patient identified as the sound of barrage. The external
environment gradually became feebler in outline, the detonation of
his auditory aura more and more violent; panic seized him; he felt
as though he were about to die and very often lapsed into unconscious-
ness. In most instances this was accompanied by violent fear and a
struggle to emerge from this state; occasionally he succeeded, but
more often he succumbed. He sometimes relaxed his sphincters. He
did not know whether or not he had convulsions. He had been told
that he lay limp. He awakened from these spells with a feeling of
exhaustion and panic and did not recover from this sensation for days.
After the spell he usually had a fear of going out of the house and a
marked sensitivity to noise, an extreme irritability, and so on.
Occasionally the spell was provoked by some incident in the
environment, and on two occasions the incident was very char-
acteristic. He was sitting in a restaurant, his mind unoccupied and in
a rather indolent mood. Two things occurred simultaneously. He was
watching the man behind the counter cut a piece of meat. The idea
of cutting, that is—that something was being cut—was associated in
his mind with a great deal of panic. As he was thinking of this, some-
body dropped a cup and saucer on the floor, whereupon the patient
gradually lapsed into unconsciousness and had to be carried home.
When asked to describe this spell, he said that it was not accompanied
by the aura of a barrage but that the idea of cutting was painful to
him; that was all he could remember. Loud noises occasionally threw
him into a spell and often accidents that “almost happened” on the
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 53
street threw him into similar panics. When the patient was asked to
describe the struggle against the spells, he said, “It is like struggling
against death.” This isa common expression used by soldiers suffering
from this condition.
The patient had almost a complete amnesia for the events concern-
ing his original trauma. He stated that he was on an ammunition
train at about two o’clock in the morning and was waiting for a bar-
rage to quiet down. He remembered that a shell came across, striking
somewhere in his vicinity; nothing further could be recalled by him
until he woke up in the field hospital where he was being treated by
a physician. While in a hospital as a shellshocked victim, he had his
first fainting spell some weeks after the shock.
As a result of these spells, the patient felt insecure and was not
able to keep any permanent occupation. The spells seemed to come
more frequently when he was at work than at any other time.
Extremely affable and agreeable, he showed no outward signs of
irritability. However, loud and unexpected noises would excite him.
Of the transference symptoms, the chief was agoraphobia, together
with claustrophobia.
He was under observation for over a year. During this interval he
had about six spells, some of them very severe. Abreaction to the
original trauma was not very successful, although when the incident
was revived, the patient had a good deal more anxiety than formerly.
During intervals between the attacks he was entirely free from fears
or anxieties associated with his spells. He had some transference
symptoms in the form of fear of crowds, subway, noise, and large
buildings.
The patient was observed in one of his spells by some friends to
whom he was talking. He became weak; his forehead began to per-
spire; he became panicky, fell down on his knees, heard a noise of
barrage, and lost consciousness. His friends related to him that during
the attack he did not froth but that he trembled all over and shouted,
“Look out! Look out!” |
Also interesting to note is that this patient never had any of the
typical dreams of the traumatic neurotic but that he frequently awoke
from his sleep with a start. He remembers none of the content of
54 THE TRAUMATIC NEUROSES OF WAR
his dreams. Possibly the ease of displacement renders these anxiety
dreams less insistent.
The following case is of chief interest because it demonstrates a
type of epileptoid reaction following upon traumatic events with the
usual secondary features of irritability, aggressiveness, and something
resembling deterioration.
Case 20. The patient was thirty-one years old. From several
members of his family it was ascertained, as far as they knew, that he
was a normal person prior to service. He was never very enterprising
or active, and from his own accounts had a marked apathy in his deal-
ings with women. He was never in love with any of them, but he had
been accustomed to a heterosexual life since his early twenties. He had
no severe masturbation conflict. The patient was never fearful in
situations of real danger, and in service he was an unusually brave
soldier. His long career of exposure to severe shelling had not under-
mined his confidence or bravery.
It is opportune in this case to describe a feature very commonly
found in those complaining of syncopal attacks. His gait was fairly
steady, but he had a rigidity in his carriage. This stiffness was most
pronounced in the movements of the head, motions executed with
rigidity and slowness, at least half as rapidly as in the normal individ-
ual. This rigidity of posture was most conspicous when he was execut-
ing movements attendant upon stimuli. The eyes would move in the
direction of the stimulus, but the head would not follow the eyes.
Moreover, he had a marked absence of the facial mimicry associated
with emotional expression, a parkinsonian facies. Here the petrified
blankness was most pronounced. Vocal inflections conveying the usual
feeling tones were likewise diminished in excursion and intensity, a
general characteristic of all these cases. Though I treated this patient
for over three years, I never heard him laugh aloud, and his smile was
generally stiff and forced.
He complained of spells of unconsciousness at intervals, varying in
duration from two days to several months. These spells were preceded
by intense vertigo, initiated at times by an aura of sparks in front of
the eyes but more frequently by nothing at all. He fell down pre-
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 55
cipitately, occasionally hurting himself. He made twitching move-
ments with his extremities, did not bite his tongue nor relax his
sphincters, but frothed at the mouth. After the spells he sometimes
felt drowsy and went to sleep. He also complained of severe head-
aches, persistent dizziness, extreme irritability, attacks of violent
temper, tantrums, assaultiveness, and marked sensitivity to noise.
When the patient was first seen, he had the usual stony, parkinson-
1an masklike expression on his face. Feeling or emotions did not seem
to disturb the immobility of the facial muscles. He came into the
room limply, sat down on a chair, and made no spontaneous state-
ments. He answered in monosyllables: “Yes” or “No,” and so on.
His behavior was very rigid. He would look out of the corner of his
eyes rather than turn his head. He hardly looked round the room to
notice any of the objects in it. Conversation held no feeling of contact
or interest for him; he was completely detached. However, any noise
that occurred or any monotonous stimulus, like the tapping of the
pencil on the table, made him extremely irritable. After he had been
under treatment for some time, the expression of his face relaxed and
became more mobile. He appeared more interested; he smiled oc-
casionally and seemed to be less fearful of his environment.
His stream of thought was always relevant and coherent. His
associations were extremely shallow, but whenever any stimulus
arose, he would make an association and then stop. The following 1s
quite typical. The patient brought a dream, which will subsequently
be described in detail. The chief subject of the dream was sand. He
was asked to associate subjects with the idea, and the only reply ob-
tained by me was, “I don’t know.” After much prompting and urging
he could only say, “Sand is what we find on the seashore.”” Whenever
he was asked to describe some of the details of the day’s events, he
would do so in the most cursory manner, something to the effect of,
“T got up in the morning; I walked around; and at night I went to
sleep.” After some urging he might inject another detail, stating
that he went to the movies. He seemed utterly impervious to any of
the things in his environment. They seemed to make no impression.
He had no trends, worries, or concerns, except that he wanted to get
well,
56 THE TRAUMATIC NEUROSES OF WAR
The patient denied having had, at any time of his life, spells of any
description. This statement was corroborated by his sister, consider-
ably older than himself. Neither could she describe any traits indicat-
ing an epileptic tendency. The patient himself, however, stated that
after he had been in service for some time, he had several minor spells
of unconsciousness, one after a severe gastric disturbance and another
when he was accidentally struck on the face. But he remembers that
these were not complete lapses of consciousness and were nothing like
the spells of which he subsequently complained.
The first real major spell occurred in the Belleau Woods. The
patient was in an engagement and was surprised by a shell exploding
near him, near enough to tear his clothes and frighten him badly.
However, he was able to go on fighting just the same. Several days
later another shell came over, and this time he was actually lifted
into the air and was unconscious for an indefinite period. All he
remembered was waking up in a hospital, a three-day journey distant
from the place where the shell exploded, altogether representing
an interval of six days or more during which he was completely ob-
livious to his environment. He said that he was “paralyzed” for a
month from the head down, that he could not move any of his
limbs, and that he stammered intermittently. After a month the pa-
tient was able to move a bit; after two months he was able to get
around on crutches. He then began to show all the symptoms of
which he now complained. He was very fearful, especially of noise;
the slightest movement of any object in the room would be enough
to throw him into a fit. Any sudden stimulus, such as someone’s
touching him on the back or suddenly passing him by, would throw
him into a state of complete unconsciousness. When he was prepared
for the stimulus, he did not mind it nearly so much. He remembered
also having been tube-fed in the hospital because he could not swal-
low. He occasionally would have fits as a result of gastric disorders
after the spells.
These spells continued up to the time of examination, a period
stretching over seven years. There was frequently no aura, but some-
times dizziness. Sometimes the aura would be a rotating wheel;
sometimes color hallucinations, which occurred without loss of con-
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES = 57
sciousness. “But when I saw black, I would always go off.” He often
imagined that the sidewalk was coming up to meet him. Trying to
protect himself from danger by grabbing a near-by object, he would
fall down. His sister volunteered the information that frequently
in these spells the patient would say things about the war, such as:
“Go and get ’em;” “kill ’°em;” and so on. Concerning the dizziness,
the patient stated that it was common and often merged into a spell
of unconsciousness. He described the dizziness as a sensation of being
revolved in a chair. During these dizzy spells he saw blotches of color
—purple, red, green, and sometimes black.
The irritability was constant and usually directed toward loud
noises or unexpected stimuli of some kind. Closely related to this
irritability was the aggressiveness which the patient described as an
entirely new trait and one foreign to him before the onset of his ill-
ness. His aggression was very frequent in his sleep. He knew this from
the fact that his brother, with whom he used to sleep, would fre-
quently wake him up with the query, “Whom are you fighting
with?” or “What are you fighting about?” And on many occasions
he struck his brother in his sleep. This aggressiveness would fre-
quently occur after his spells, when he would be seized with a desire
to fight and to break up objects in the room. His sister stated that he
had smashed many articles of furniture and innumerable dishes. Ac-
cording to the patient, these aggressive impulses were not preceded
by anger.
The dream life of this patient was typical of the traumatic neurot-
ic, but it also showed some new interesting features. As usual, the
dreams were concerned with fighting or with being attacked. Their
content varied: dreams of falling, burning, drowning, being electro-
cuted, reproductions of war scenes. He used to remember his dreams
vividly, but now he remembered very few of them. Only after a
great deal of effort could some of his dreams be collected. The dreams
of this patient dealt with the “sado-masochistic” conflict but were
almost entirely concerned with being annihilated. During periods
in which the patient was relatively free from symptoms, he would
have dreams in which he was the aggressor. “I dreamed I was fenc-
ing with someone, and I stabbed him.” He would awake frightened.
58 THE TRAUMATIC NEUROSES OF WAR
The anxiety problem in this case is of great interest. The dreams
all indicate a marked activity of anxiety which, however, the patient
was incapable of displacing on any situation in the outside world.
He had no anxiety except that associated, in a general way, with the
feeling of being killed if he had a spell in a dangerous situation. Aside
from this was no conscious representation of anxiety. The patient
had no agoraphobia. He would spontaneously avoid exposing him-
self to danger. The violent anxiety from which he would start in
his dreams would not disturb him in his waking life. For short periods
after waking from his dreams, he would have transient fear of the
dark, fear of loud noises, fear of burglars, and so on; but this seldom
lasted more than a few minutes, and then he would promptly go to
sleep again, only to be awakened by another dream of the same kind.
The relationship between the anxiety and the loss of consciousness
was explained to the patient, and he was urged to anticipate the at-
tacks of unconsciousness by actually fearing them. After considerable
persuasion, the patient brought certain phenomena to indicate that the
anxiety so active in his unconscious could be brought into closer re-
lation with his spells of unconsciousness. He came to the clinic very
excited, apprehensive, fearful, and trembling and stated that for the
past four days he had been in a constant state of apprehension but
that it was not displaced upon any situation in the external world.
It was, however, displaced upon his spells. Thereupon the patient
recalled that he had, on many occasions, been in apprehensive states
during the past seven years but had feared nothing in particular. It
had never formulated itself as a definite phobia. Moreover, he said,
the presence of these anxieties did not guarantee or prevent the oc-
curence of his spells, because he would frequently go from one of his
anxiety states directly into one of his spells. Several days later the
patient brought an interesting phenomenon. He was awakened by one
of his typical dreams and switched on the light to get a pencil to
describe his dream, as he would otherwise completely forget it. He
remembered nothing beyond switching on the light; he then went
into a spell. In short, an attempt to bind the anxiety to a special situa-
tion failed. Certainly the inability to make transference to the outer
world was responsible not only for the fact that the patient had no
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 59
phobia but that the spells persisted in their original form, together
with these violent dreams. In these dreams repressed anxiety con-
tinually emerged in conjunction with the original situation but left
no trace in his conscious life.
Although prior to service a steady and industrious worker, he had
not been able since service to apply himself to any work. Whatever
interests he showed on fleeting occasions were directed along mechani-
cal lines. He had several times attempted to devise various implements
of a mechanical nature, usually labor-saving devices. The patient
could not work because he could take no interest in any activity. As
he put it, “Whenever I make any attempt to work, I am thrown into
spells more frequently.”” Other features of this case have been re-
served for later treatment.
The following case is an excellent demonstration of epileptoid
reaction to a traumatic situation. The interesting feature in it is that
anxiety dreams and all conscious traces of anxiety have completely
disappeared. There are no transference symptoms, and all consequent
spells are unusually severe and persistent.
Case 21. The patient, now thirty-three years old, had been under
more or less constant treatment for about eight years and hitherto
had noted practically no improvement in his condition. He had abso-
lutely no history of convulsions or of fainting spells at any time in
his life. Not a neurotic child, he was not afraid of the dark and had
no animal phobias. In childhood he was a sociable, affable boy, fond
of sports appropriate for his age. He was not subject to tantrums
or severe states of obstinacy. At the age of seventeen he hurt his
left elbow when he was injured by a streetcar. No after effects were
noted. His love life developed in a normal way.
After a brief training in the United States, he was sent abroad. He
was just preparing to enter the front lines when he received a small
shrapnel wound in the thigh. He stated that at this time he was not
particularly apprehensive or fearful in any way and did not take
his wound seriously. He was sent to an English field hospital. On the
evening of the day he was wounded, the patient was napping in the
hospital when an airplane dropped a bomb on it, and the patient was
“blown up.”
60 THE TRAUMATIC NEUROSES OF WAR
The next thing he could recall is his waking up in Boulogne a long
time afterwards. He could not talk, he was all tremulous, and his
feet would not support him. During this period the patient did not
maintain consciousness continuously, but kept “dipping”— that is,
intermittently he kept lapsing back into a state of unconsciousness.
He had to be confined for a long period in a padded cell or strait
jacket. For this period the patient had now almost a complete am-
nesia and a well-marked resistance to talking about anything con-
nected with it. His conduct during this time was evidently delirious.
How long these states of unconsciousness continued, the patient does
not know; but when he was finally able to maintain consciousness,
he stammered, trembled, was subject to anxiety dreams pertaining
chiefly to airplanes flying over his head, was very sensitive to loud
noises and abrupt stimuli. This condition remained up to the pres-
ent time.
When he came to the clinic, his symptoms were periodic spells of
unconsciousness, sensitivity to noise, inability to apply himself to
work, and restlessness. He had no transference symptoms of any kind,
did not fear riding in the subway except that he did not like the noise,
had no phobias of any description, no anxieties, no anxiety dreams.
The patient was observed in one of his spells in which the following
occurred. The spells were always preceded by headaches which “began
low down in his spine and traveled up” and which were very severe
in character, more like muscular cramps of the neck muscles. The first
thing he noticed was the inability to maintain a forward position of
the neck. The patient became cyanotic, losing consciousness at the
time, but was able to perform voluntary movements. On one occasion,
during this phase, the patient was able to walk about twenty paces to
a seat. The next phase of a spell was an outburst of violence; the pa-
tient threw up his hands, fell to the floor, but did not have convul-
sions. The movements seemed to be codrdinate and very like the
movements of a person fighting someone. This phase lasted for about
two or three minutes, during which time his fists were clenched and
he was striking and tearing violently while on the floor. There would
be occasional relaxation of the sphincters; sometimes he would bite
his tongue. Frequently during this phase the patient would break
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 61
and tear objects around the house; he broke many chairs, tore up
sheets and pillows, but never harmed any person or injured him-
self.
After this violence had subsided, he lay mumbling with his eyes
open but did not hear anything said to him. When he was touched,
he made defense movements; in fact, he was hypersensitive to this
type of stimulus. Some time after this subsided, the patient made some
remarks or inquiries concerning his whereabouts and concerning some
member of his family. He had no persistent aura, and the attacks
occurred at intervals varying between one to three weeks. His stam-
mering had continued unchanged for the past three years.
The patient’s lack of emotion concerning the original trauma was
unusual. He related it as a matter of course. During the entire period
of treatment it was impossible to reactiviate any anxiety in connec-
tion with the original accident. However, he showed unusual strength
and emphatically refused to enter into any discussions about it, al-
though he denied that such discussion would be painful for him. In
other words, the original trauma and all its secondary ramifications
seemed to be entirely encapsulated and to have no apparent con-
nection with the patient’s other psychic spheres. The prognosis, there-
fore, appeared to be practically hopeless, since no bridge remained be-
tween the patient’s conscious life and the activity of the trauma in un-
consciousness. It must be noted that the secondary so frequently found
in these cases, namely, the withdrawal of interest from the outside
world and from other people—particulary members of his family—
were very much less marked than is customary in these cases. He
was intensely devoted to his wife and child and was extremely tender,
never showing any signs of irascibility or temper toward them. To-
ward the physician he never assumed an attitude of dependence, and
hence anything in the nature of a transference was impossible.
The following case is a typical case of epilepsy developed after a
traumatic event and difficult to differentiate from essential epilepsy.
Case 22. The patient was thirty-two years old. The chief complaint
he presented was spells of unconsciousness. These spells corresponded,
in every detail, to those of essential epilepsy. He had an occasional
62 THE TRAUMATIC NEUROSES OF WAR
aura in the form of pain in his chest. He would fall abruptly, fre-
quently cutting and injuring himself. His convulsions were typical.
Several were observed in the clinic. He would not always relax his
sphincters but would bite his tongue. The spell was invariably fol-
lowed by a stuporous sleep of variable duration. The first of these
spells occurred while he was in a hospital convalescing from a shrap-
nel wound in his left buttock and an attack of gassing. The patient
stated that he was “knocked out on the battlefield.” He gained con-
sciousness in the hospital. Originally, he stated, he had the typical war
neurotic phenomenon of dreams of the war scenes from which he
would wake in great fright. He used to remember some of these
dreams, but they had become so stereotyped that he no longer re-
membered their content. However, they were infrequent at the pres-
ent time, although originally they occurred night after night.
The patient had some fears, but they were secondary to his all-
important spells. He feared riding in the subway. Because he feared
the oncome of a subsequent attack, he carefully avoided exposing
himself to any danger. This type of fear is frequently found in true
epilepsy. The spells were not accompanied by anxiety, and at the pres-
ent time there existed almost no representation of the consciousness
of fear or anxiety. There was no evidence of deterioration. The pa-
tient’s affect was entirely normal toward his illness.
He showed some typical features of epilepsy. He was hard, rigid,
immobile. He had no conversation; he volunteered no information.
His illness, had, however, few displacements, with no evidence of
conscious conflict. When he talked about his former anxiety dreams,
he usually laughed them off, saying, “Oh, they used to be terrible,
but Iam so familiar with them now, I don’t mind them.”
From his history it was difficult to decide whether or not the patient
lost consciousness on the occasion of his original trauma. His first
attack in the hospital was not a convulsion but an attack of acute excite-
ment, during which he ran out of bed, tore his clothes, smashed the
furniture, and had to be led back and tied to the bed. The attacks
which followed, however, were true convulsions.
His dreams were typical of traumatic neurosis: being attacked,
trampled on, electrocuted, drowned, and so on. During his seizures
he would wet the bed occasionally.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 63
The above presented case is that of a typical epileptic who, al-
though his illness was eight years old, did not show any sign of de-
terioration. He had no auras preceding his seizures, and no neurotic
displacements of any kind. He had a rational fear that something
might happen to him in one of his spells; he continued to have some
disturbing dreams, not unlike those frequently encountered in es-
sential epilepsy without traumatic provocation.
In order to demonstrate the independence of the resulting symp-
toms from the character of the traumatic experience, organic or other-
wise, I have selected two cases, one of which followed a fractured
skull. The other was unprovoked by any trauma in the ordinary, ac-
cepted sense of the word.
The interesting point in this case is that “fractured skull’? was the
diagnosis made on his original condition.
Case 23. The patient’s previous life was uneventful. In Siberia he
had a prank played on him. He was awakened in the morning and
tossed up and down in a blanket in his nightclothes. Falling out of
the blanket, he landed on his head and was in a state of unconscious-
ness for about a month. He had a complete amnesia for all the events
preceding the accident. The story, as he now told it, was reconstructed
by the patient from fragments related to him. During the month of
unconsciousness he was said to have set fire to the hospital several
times. Since then, the patient had been subject to lapses of uncon-
sciousness lasting for twelve hours to eleven days. He was later told
that he was taken toa hospital and that he was fully awake during these
lapses, was active, smoked, read, and talked but was not his conscious
self. He was also told that he did not appear to be his “right mind.”
These major lapses of unconsciousness occurred at intervals for five
years. Since that time he had had only minor ones. They usually be-
gan with a feeling of paralysis in one extremity, either an arm or a
leg. Sometimes it was only an attack of vertigo.
The only other symptom elicited was a compulsive urge to attack
or strike people. He could not stand on high places or ride horses;
he had a compulsion to jump from high places. He never had trans-
ference symptoms nor the usual type of annihilation dream. More
recently he had been subject to transient spells of blindness which
64 THE TRAUMATIC NEUROSES OF WAR
lasted four or five minutes. When he was well, the patient went about
his activities.
The loss of consciousness, transient blindness, and amnesias are
quite like those in true traumatic functional cases. The sadomasochistic
conflict is also present in the form of a compulsion to strike people.
The following case is of interest because it demonstrates to what
extent the symptoms of true epilepsy may resemble those of traumat-
ic neurosis.
Case 2 4. The patient was twenty-seven years old. In 1918, while on
duty, the patient was in the kitchen with five other men when the
shack they occupied was struck by lightning. All of them were dazed.
He alleged that his own dazed state lasted only two or three minutes.
During this time he did not know where he was, nor had he any idea
of what had occurred. Although he had no pain or sensation of any
kind accompanying the shock, his arms and legs were discolored and
blue. He was given some form of physiotherapy, and the discoloration
disappeared after a few hours. Within two hours after the accident
he was as normal as ever before. He did not recall that he suffered
from disturbances of sleep.
Within a short time the patient began to have symptoms referable
to his gastrointestinal tract. Severe pains sometimes “doubled him in
two.” It was diagnosed as “acute appendicitis,” and he was operated
upon. His hospitalization lasted for thirty-six days, his convalescence
being uneventful except for a superficial opening of the wound. He
did not fear the operation, he stated.
About a year and a half later he began to have a repetition of the
symptoms which initiated his acute appendicitis, the severe pain, and
so forth. On one such occasion this pain attacked him on the street;
he lost consciousness and was brought home by some strangers. He
was told by an observer that during this spell he dug his nails into
his stomach. Since then these spells recurred on an average of two or
three times a week. At first they were preceded by the characteristic
aura of gastric colic; after two years this aura disappeared, and his loss
of consciousness came abruptly. With regard to these spells, he did
not know just how long they lasted, whether or not he relaxed his
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 65
sphincters, bit his tongue, or whether or not the convulsions were
tonic and clonic in character.
About a year after his first spell, the patient began to suffer from
a disturbance of sleep. He would have difficulty falling asleep; the
slightest noise would awaken him. After such an awakening he could
not get any sleep for the remainder of the night. He became particu-
larly sensitive to loud noises during the day.
About 1921 he began to have the typical “sadomasochistic”’ dreams
—being trapped by fire, being chased by someone, fighting, being
beaten and annihilated. Often his sleep was disturbed two or three
times during the night. Of late, although these dreams continued,
he had so learned to control his sleep that he did not awaken. How-
ever, on awakening he often found that he had been injured during
his sleep. His spells were often nocturnal, passing from a dream
into a spell. He shouted, struck the wall and the bed, and was usually
bruised on the head and arms.
During the day he suffered from spells of dizziness with black
blotches in front if his eyes. These spells occurred sometimes as often
as three or four times during one day. They occurred especially when
he made a sudden move, got up out of a chair, bent over or stood up
from a reclining position; in fact, any and every locomotor change
affected him similarly. He was not sensitive to loud noise in the day-
time.
Another important change in his character was his extreme irrita-
bility. “If things do not suit me, I get very crabby. I must have my
own way.” He also suffered from amnestic states and had been ap-
prehended by the police several times. The last incident was probably
typical. He remembered leaving the office at six o’clock but had no
recollection of where he went. He kept on walking, was found by an
officer, and sent home. He had often been found fifteen or twenty
miles away from his home. His behavior after his spell was note-
worthy. His limbs ached, he was disorientated, and he had a desire
to sleep. Somnambulistic states were a frequent occurrence with him,
that is, the psychic equivalent.
Very sensitive to the sight of suffering, the patient could not bear
seeing others injured or hurt. He had no transference symptoms, no
66 THE TRAUMATIC NEUROSES OF WAR
anxieties of any kind, and was not fearful of any situation, such as
theatre or subway. He was also not afraid of the consequences of his
spells, As far as he knew, he was not more religious than formerly
and was not dishonest or selfish.
This is a case of essential epilepsy, the chief interest of which lies
in the similarity between it and typical cases of traumatic neuroses.
The aura which initiated his attacks was a distinct reference to a
traumatic experience, the symptom which initiated an organic illness.
Of course, another and more likely interpretation is that the patient
never really had appendicitis and that the gastric symptoms were
the result of a spasmophilic crisis, so often found in isolated forms
of traumatic neuroses. This aura has since dissappeared, and the only
trace of anxiety is to be found in his dreams. The diagnosis of epilepsy
is confirmed by the absence of transference symptoms and the pres-
ence of somnambulism, twilight states, and amnesias. During his
hospital residence he complained chiefly of headache and dizziness
lasting for days at one stretch. He would wear an agonized expres-
sion all this time. He was observed in one of these states to be cyanot-
ic and rigid but without complete loss of consciousness.
The “epileptic character,” so-called in this case, appears to be en-
tirely lacking. His past history does not bring out any tantrums, in-
tolerance, impatience, egocentricity, overscrupulousness, or religiosity.
His behavior during observation showed these traits to be com-
pletely absent. Neither was he obliging to a saccharine degree as many
of these epileptics are. His intelligence was not as keen as it had
formerly been, and his emotional tone was decidedly low. He spoke
with very little force, was pleasant, though not particularly engaging.
His attitude toward work was normal, although when he did work,
his spells occurred much more frequently.
SUMMARY
A traumatic experience can precipitate any of the well-known
types of neurotic or psychotic disorders. However, irrespective of the
nature of the resulting clinical picture, there are always the distinc-
tive features of the traumatic neurosis.
SYMPTOMATOLOGY OF TRAUMATIC NEUROSES 67
The presenting symptoms of this neurosis vary according to the
time of observation. There are acute, transitional and stabilized forms.
The type which stabilizes most rapidly is the one concerned with
sensory-motor disturbances. The other stabilized forms vary only
in the degree to which one feature is emphasized over another. In
some cases—the defensive ceremonials—the organization of the neu-
rosis is very high. In others the sensory-motor phenomena predomi-
nate; instill others autonomic, or epileptiform phenomena occupy the
facade. It often happens that the emphasis will shift in the same case
from epileptiform to autonomic symptoms. The neurosis also brings
with it certain definite alterations in the character of the subject, and
this change is almost uniform, irrespective of the symptomatology.
The one exception to this occurs in those cases with motor paralyses.
The combination of a varying symptomatology with a uniform alter-
ation in the character of the subject indicates a neurotic process which
can be studied systematically.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
_
Ill, ANALYSIS OF THE SYMPTOMATOLOGY
Our FIRST PROBLEM is to decide what kind of entity the traumatic
neurosis is. To this end a comparison with hysteria and compulsion
neurosis would be helpful. These latter neuroses deal with certain
unsuccessful types of integration, some of which constitute the charac-
ter of the individual and others which terminate as symptoms. The
most noteworthy feature of these character traits and symptoms is
their interrelation. Morover, both character traits and hysterical
symptoms are related to definite aspects of the personality—those
aspects of adaptation which deal with relations to others; attitudes to
oneself; problems of status, connected with the question, ““What do I
think of myself?”; and finally, certain drives toward satisfaction
of biologically determined needs—sexual—and those determined
by social values,—prestige.
To anyone acquainted with the clinical manifestation of the hys-
terias, obsessional neurosis and character disturbances, the contrast
of these traumatic neuroses is very striking. We have already pointed
out the lack of displacement phenomena, a fact seeming to indicate
that the psychic elaborations of the forces creating the symptoms is
very poor. And this in turn would lead us to suppose that aspects
of adaptation not involved in the hysterias and obsessional neuroses
are touched on. If this is the case, we must proceed at once to examine
the nature of the traumatic experience.
WAR AND THE TRAUMATIC SITUATION
One of the facts clearly established by the clinical phenomena is
that the symptoms make a series, many features of which can be found
in all cases, irrespective of the nature or severity of the traumatic
experience, We are, therefore, dealing with specific reaction types
which are responses to an alteration of the entire problem of adapta-
tion. What, then, is the nature of “trauma” which ushers in these
altered forms of adaptation?
ANALYSIS OF THE SYMPTOMATOLOGY 69
Certainly the war situation—particulary modern warfare—creates
these traumatic situations’ more frequently than peacetime conditions.
Even when the finer differential diagnosis of traumatic neurosis was
not known, certain sequelae of war could always be noted. Thus Awto-
kratow (12) reports that one of the most noteworthy consequences of
the Russo-Japanese conflict was the inordinately high increase in
epilepsy.
The war situation definitely contributes to the frequence of inci-
dence of traumatic neuroses and allied diseases and is undoubtedly
responsible for the difference in character between these neuroses and
those which occur in peace time in a more attenuated form.
Modern war has introduced certain conditions conducive to neuro-
ses in those so predisposed. The resulting traumatic situations are
more numerous. This above-mentioned high incidence of postwar
epilepsy is due entirely to the epileptoid character often assumed by
the traumatic neuroses. The use of high explosives, gas, submarine,
airplane makes the dangerous situations in modern warfare more fre-
quent and more difficult to escape. These unpredecented and horrible
situations in modern warfare, as is reasonably believable, have some
direct relation to the severity of the neuroses that ensue; some trau-
matic situations are more conducive to violent neurotic types than
others. One cannot, however, but feel that the war situation, with all
the accompanying horrors, rather colors the intensity of the neurosis
than gives it its essential character. This follows from the fact that the
traumatic neurosis is primarily a fixation phenomenon, accompanied
by repetitive process, with a group of secondary defense mechanisms.
A patient blown up by a shell and remaining unconscious for forty-
eight hours is more likely, in the ensuing neurosis, to have symptoms
which reproduce certain conditions of the original trauma than 1s a
man exposed to a whole series of petty insults.
*A neurosis named after the situation which provokes it, rather than from some
general characteristic of the reaction, is misleading. This we shall try to remedy. Mean-
while, we must preserve the name “traumatic,” and use it to cover all those syndromes
which are variously designated according to the provoking situation, as was the case
with “shell shock,” lightning neurosis, railroad spine, etc.; or according to the specialist
to whom the case was assigned, depending on the nature of the presenting symptom, @.g.,
neurocirculatory aesthenia, autonomic imbalance, etc.
70 THE TRAUMATIC NEUROSES OF WAR
Thus, while the war cannot be said to have produced any specific
neuroses, the modern military situation with its inexorable weapons
creates more difficult situations to escape and thus activates disorgani-
zation of the ego. But a direct continuity exists, as we shall see, be-
tween the mildest and the most severe of these reaction types.
Another situation concerning the late war, that is, the issue of post-
war compensation, also conduces to the special character of the chronic
forms. This compensation becomes an overt secondary gain of illness.
But even here, it may be anticipated, the indemnification issue does
not in any way create the neurosis. The demand for and the depend-
ency upon compensation is an essential and unconsciously determined
defense mechanism and cannot be considered a prime factor, although
it is often an obstinate source of resistance in treatment and rehabilita-
tion. As a matter of fact, this situation is not restricted to war. Hardly
a civilian situation exists in which traumatic neurosis is not compli-
cated by the issue of compensation for damages.
Although peacetime traumatic neuroses may differ in no qualita-
tive manner from those encountered in the war, several conditions
prevailing in the war situation and absent in peace may, in those so
disposed, make the neurosis easier to become stabilized. These fac-
tors deserve consideration as quantitative and aggravating rather
than causative agents, though their exact effect on the intensity and
frequency of the neurosis is indeterminable.
On superficial examination, so far as the “instinct”? life of the indi-
vidual is concerned, the war situation is very different from that of
peace. Perhaps the most striking dissimilarity lies in the apparent
difference of the goal of activity. The general assumption is that the
goal of activity in war is the annihilation of the enemy and the pres-
ervation of self. This is apparently a wide departure from the goals
and the pursuits of peacetime. But the difference diminishes on closer
examination. The egoistic pursuits of peacetime are, for a large num-
ber of individuals, purely self-preservative in character. They are
obliged to work in order to exist, and this statement becomes truer
perhaps in proportion as the work involved is of a cruder character. In
the case of peacetime pursuits, the self-preservative issue has no ur-
gency and no immediate danger. It takes time to starve, and with our
ANALYSIS OF THE SYMPTOMATOLOGY 71
modern social organization starvation becomes a rather difficult pro-
cedure. The self-preservative issue in peace is implied rather than
apparent.
Our social organization has conferred upon the individual a high
degree of culture and differentiation of activities (originally used to
fight beasts and enemies) into the refinements of labor. On the sur-
face these latter seem to make little claim upon the same elementary
drives activated in the fighting of wild beasts and enemies. Social
organization has removed some elements of immediate danger. It
has made possible the remarkable and systematic conquest and ex-
ploitation of the physical environment and has thus transformed the
primitive egoistic anxiety to the form of constructive work.
The state of war is therefore at the very outset an anxiety-provok-
ing situation. Though similar to those of peacetime, the activities of
war represent a stripping of the refinements built up by social organi-
zation, with the effect of releasing a great deal of anxiety in the form
of fear of impending danger; thereby incurred is a greater burden
upon those impulses which ordinarily find their outlet in the primitive
fight against the environment.
In addition to this is another important consideration, namely, that
the war situation strips the individual of the protections of peacetime
activity. During the conditions of peacetime the work of the individual
is regulated as regards intensity, duration, and character by certain
conventions which rest eventually upon the essential and unalterable
physiological characteristics of man. Thus, in peacetime, the hours of
labor are regulated with due regard to the normal conditions of fa-
tigue and the normal fluctuations of diurnal efficiency. Moreover, in
peacetime the character of the work to be done is, to some extent, sub-
ject to individual option for the greater number of men. We need
not emphasize the absence of sexual gratification in war, the paucity
of entertainment, poor food, or unhygienic surroundings, all of which
make the environmental conditions of war and the demands on the
psychic organization of the soldier enormous.
A large number of the factors above considered—those regulating
fatigue, efficiency, hygiene factors, and even sexual outlet—appear
to be physiological rather than psychological problems. Yet although
72 THE TRAUMATIC NEUROSES OF WAR
the physiological hardships of warfare are undoubtedly alike for
those who get neuroses and for those who do not, one is tempted, in
this regard, to take issue with the point of view of the organicist who
explains all these phenomena with the formula of “organic insuffi-
ciency.” That is, a soldier is supposed to have an unstable autonomic
system, therefore he succumbs to a neurotic disturbance involving the
autonomic system. This type of explanation is one of the oldest and
illustrates one of the most persistent of psychiatric forms of begging
the question. Accordingly, the organicist explains the phenomena of a
neurosis by the mere assumption of an unstable, inadequate, or in-
ferior nervous system and postulates that the reactions resulting there-
from are psychological reactions to the inadequate functionings of
these various systems. The fallacy of this argument can be under-
stood by contrasting the following situations: When a person, through
the urgency of the situation, is obliged to avoid a stronger adversary
than himself and must continue to do so until he falls down exhausted,
we have a phenomenon generally understood without more explana-
tion. He reaches the limits of physiological endurance. This, we may
say, represents primarily a physiological problem. But on the other
hand, when such an individual continues to have the same symptoms
of exhaustion, rapid pulse, easy fatigability, fainting spells, and epi-
leptoid symptoms long after the urgent situation has ceased to exist,
we have a right to question the belief that these symptoms are physio-
genic. The fixation phenomenon, with all its psychological accompani-
ments of inhibition and reaction formation, ceases to be a physiological
problem.
The problem of adaptation in the war situation is a wide departure
from the conditions of peace. The soldier is, to be sure, a member of
a group and is, to a variable extent, identified with the other members
of it and with the nation and the cause for which the enterprise is
launched. This latter feature, the identification of the individual with
the cause of the war, is likely to be subject to a great deal of varia-
tion in modern wars, where conscription is the rule. The average sol-
dier feels the war to be the seat of the danger. Rarely does he know
or perceive the original causes of the war which is being waged, pre-
sumably, for his protection. He is seldom touched by these issues di-
ANALYSIS OF THE SYMPTOMATOLOGY 73
rectly. He is much more touched and intimidated by the military
regime, its rewards, and punishments. The extent to which the soldier
can identify himself with the cause is important only insofar as it
enables him to be interested in the activity. When the remote rewards
of personal advantage are absent and the cause of the war is abstract
patriotism and the supposedly hated qualities of the enemy and when
he is held in check by a discipline more or less inflexible and inescapa-
ble, one must say that the soldier suffers in the modern war situa-
tion a privation hard to equal in any situation in civilian or even primi-
tive life. Undoubtedly the ability to be interested in the activities of
war depends, in part at least, on the narcissistic objectives which the
individual soldier is able to anticipate. When war has the tangible
objectives of profit, security, defense of an ideal, and rewards not
too remote as far as the individual is concerned, it would be easier to
endow the activity with interest. But in modern war this is possible to
limited degree. A state of affairs exists very like that in modern in-
dustry. A man who works in a factory does not have the objective of
the completed product of which he makes or adjusts a single part. He
cannot have much “pride of workmanship.” Such work is tedious,
and the interest must be shifted entirely on the reward in the form of
money. In war the enforced replacement of his own ego-ideal with
that of the group precipitates an egoistic conflict of great violence and
creates an ambivalence toward the group, at once as his persecutor
and protector. The more completely the soldier is identified with the
cause and the leaders and the more firmly he is bound by ties of in-
terest to the group, the better able is he to take care of the unprece-
dented violence of the anxiety released by the war situation. A situa-
tion not dissimilar to this, although entirely lacking in urgency, exists
in certain labor conditions of peacetime.
This, together with the fact that the violence of warfare creates
conflicts which in peacetime must exist in lessened form, plus the ur-
gency, the inescapable character, and the rapid succession of events—
all of these conditions foster disorganized adaptation types which
under ordinary civilian conditions cannot arise except in great public
calamities like pogroms, extensive fires, earthquakes, tidal waves,
volcanic eruptions, and so forth. War is therefore a situation which
74 THE TRAUMATIC NEUROSES OF WAR
necessitates radical changes in adaptation as compared with that of
peacetime. However, none of these changes would be effectual with-
out the actual traumatic situation which exists in the form of exposure
to severe shocks and injury. It therefore becomes essential to define
the concept trauma.
WHAT Is A LRAUMA?
Trauma means injury. When used in a psychological sense, this
connotation of injury must be altered, for we must define what is
injured; here we encounter some difficulty. Properly speaking we
would say that an adaptation is injured, spoiled, disorganized, or
shattered. We can also speak of an injury to the ego, merely another
way of saying that adaptive processes are altered. A trauma can-
not be defined either in terms of the provocation or the reaction to
such provocation alone, but as a relationship between an external
stimulus and the resources immediately available to adjust to, side-
step, or otherwise master the stimulus. This is very different in the
traumatic situation occasioned by an external stimulus as against one
created by an autochthonous stimulus like wishes, urges, or drives
from sexual sources. Among other things is a time factor, for most
traumatic situations are sudden and overwhelming. Let us try this
working definition of trauma on a few situations.
The act of attention.
. Fatigue.
. A sudden pain.
. Aslight accident.
. A fractured skull.
. Arteriosclerosis.
. A brain tumor.
Anuhwor a
~I
1. An act of attention. Perhaps all the situations mentioned in this
list may be considered “traumatic,” but why include the commonest
phenomenon of conscious life in this category?—because it arrests
an existing equilibrium, makes necessary a new adaptation, and sets
the organism in a state of preparation for a new change in certain
adjustive mechanisms. It narrows or focuses the field of consciousness
ANALYSIS OF THE SYMPTOMATOLOGY 75
and is accompanied by some muscular immobilization which can be
considered a preparation for new activity consequent upon the new
perceptions involved. The immobilization phenomena are most con-
spicuous in the case of auditory stimuli, less so with visual, tactile,
olfactory, and gustatory stimuli. Therefore an act of attention in-
volves perceptual, codrdinative, and executive capacities and is gen-
erally not traumatic because in most instances it leads to an adequate
adaptation, whether it be flight from an offending stimulus or the
solution of a mathematical problem. In many disorders of attention
it is not difficult to trace the origin to anxiety, which means that the
adjustments demanded are beyond the ready capacities of the indi-
vidual.
Thus a boy of fourteen suffers from an inability to comprehend
anything connected with algebra though his intelligence is otherwise
average. [he inability to be attentive to mathematics began with very
early impressions about its difficulty. When it became necessary for
him to do a mathematical problem, be became confused and anxious.
His only adaptation was to ask someone to do it for him. His incapac-
ity was an inhibition of attention premised by the unconscious idea,
“T cannot do that,” and it went to a complete paralysis of any execu-
tive capacities with respect to this circumscribed activity.
2. Fatigue. A more complicated picture is presented by fatigue.
This phenomenon hardly corresponds to the general concept of trau-
ma. The only reason to include it is that we stressed in our pre-
liminary definition a reduction of resources. Many of the phenomena
encountered in fatigue closely resemble those of the traumatic neuro-
sis—the irritability, lack of codrdination. The dream life of the fa-
tigued shows some characteristic features which, though minus the
catastrophic character of the traumatic neurosis, do show the inability
to consummate effectively some activity like running but never reach-
ing the destination. (See for further details pp. 88-89.)
3. A sudden pain. Let us now examine a phenomenon more obvi-
ously traumatic—a sudden pain. Many individuals under these condi-
tions faint. This is a complete withdrawal reaction through cessation
of consciousness. Other reactions are crying, jumping. If the pain
is produced by an individual, some bit of aggression against the ob-
76 THE TRAUMATIC NEUROSES OF WAR
ject is most likely. In the case of fainting we have, therefore, instead
of a tonic state of preparedness, a complete collapse of the whole per-
ceptual and executive apparatus.
4. A slight accident. For the following case I am indebted to the
late Dr. Monroe A. Meyer. It concerns a young woman, quite a nor-
mal individual. One day, while she was combing her hair in the bath-
room, the flushing apparatus suddenly became dislocated and, as it
fell, struck her a glancing blow on the shoulder. Though she was not
hurt, the suddenness of the accident frightened her. She felt rest-
less, uncomfortable, and could not pursue the normal routine of her
daily activities. She lay down to rest but was “nervous,” irritable, and
apprehensive. She succeeded in falling asleep only to be awakened
several times during the afternoon by dreams photographically re-
peating the incident of the bathroom. For several days she was some-
what “jumpy” and the dream recurred a few times; then it was com-
pletely forgotten.
5. A fractured skull, Another case concerns a man of twenty-six,
struck in the left temporal region by a bus which suddenly swerved
out of line. He lost consciousness and, when revived, noticed that
five minutes had elapsed since the moment he was struck, for he had
noticed the time a second or two before the accident. He noted also that
he was bleeding from the left ear and, being a physician, thought that
in all likelihood he had a fractured skull. He directed some people
who picked him up to notify the friends expecting him for dinner and
argued with the policeman about the hospital to which he was to be
taken. He had his danger clearly in mind, knew all the symptoms he
might expect as a result of a fractured skull, but was not panicky.
When removed to the hospital of his choice and cared for by his own
physician, he began to feel worse. He became mildly dazed and
slightly stuporous, but when examined watched the neurological ex-
amination carefully. He inferred from the absence of a left abdominal
reflex that he had a contrecoup laceration of the brain.
During the first few days he continued in this dazed, semistuporous
condition induced partially by use of narcotics and slept most of the
time. During the first few nights he had violent nightmares from which
he awoke fearfully frightened and considerably dazed; more often
ANALYSIS OF THE SYMPTOMATOLOGY a7
he could not remember the exact dreams, although he knew they
were terribly harassing and involved some threat of annihilation.
During the following days he was extremely excitable, irritable, and
sensitive to persistent noises, though he was completely deaf in the
left ear. On the sixth night he had a dream of a nude woman pass-
ing before him, but in the dream he remained completely unmoved
by it. His interpretation of this dream was: “I suppose this is no
time to be thinking of women. I have other interests to preserve.”
From the seventh to the twelfth nights he continued to have disturb-
ing dreams. Their content included combats, police, race-riots, Jews
fighting Chinamen, and so on, although in the dreams of this period
he was not in any personal danger. He then began to dream of foot-
ball games and baseball games.
During this last period his fantasies in the daytime were occupied
entirely with his desire to get back to work and with the wish to re-
cover rapidly, since he was extremely anxious to resume his normal
routine activities. He often had dreams in which he was back at his
work but was interrupted by continuous frustrations. Finally a dream
which took place in a schoolroom was accompanied with some anxiety
connected with examinations. This terminated by his saying: “Why
worry about school? I don’t go to school any more.” This was the
last dream of any kind he remembered. His convalesence was un-
eventful, and he recovered completely, save for a partial deafness in
the left ear.
A psychologist friend sent him a toy Fifth Avenue bus as a gift,
toward which he had a typical fear reaction at first; but after he left
the hospital, he showed no fear of passing busses, though he was more
careful than he had formerly been. Of the residual symptoms, irri-
tability, fatigability, and irascibility persisted for some time and then
disappeared. These traits were all foreign to his native character.
6. Arteriosclerosis. A man of forty-three had begun to suffer from
arteriosclerosis at the comparatively early age of thirty-six. During
the last year of his life his symptoms were so severe in their mani-
festations that he felt himself constantly threatened by death, and he
often spoke about it to his friends. Though he rarely dreamed, for
several months prior to his death he was constantly visited by hor-
78 THE TRAUMATIC NEUROSES OF WAR
rible nightmares, the content of which was fighting, bloody scenes,
threats of annihilation; he would awaken with sweating anxiety. The
dreams in this case corresponded in all respects to those of the trau-
matic neurosis, yet no obvious trauma had occurred. He never had any
stroke, nor did he consciously have any fear of death, but he often
had spoken of the threat to his ego which his disease involved and
against which he was powerless. His dreams were evidence of the
severe curtailment of resources occasioned by his illness.
7. A brain tumor. A student of twenty-three was sent to me for
treatment of hysteria after a most trustworthy neurologist had found
no evidence of organic disease. The presenting symptom was a certain
type of convulsive seizure without loss of consciousness. The symptom
appeared abruptly. One night without any relevant antecedents, the
patient was awakened with terror out of a sound, dreamless sleep, and
his body began to convulse all over. Able to speak, he called to the
adjoining room for his brother, who tried to hold the patient in bed.
The attack subsided after about twenty minutes. The patient was not
confused but amazed by the experience and depressed. A fortnight
later he had another such attack. The patient remarked that he also
began to have vertigo, particularly on change of posture, and became
extremely susceptible to noise. He had several nightmares in which
he was being annihilated in some catastrophe and from which he
awakened. He did not have any phobia of disease.
I took him for analysis and found a rather banal situation. True,
he had a little neurosis, chiefly in the form of character traits, but I
could establish no connection between his neurotic traits and these
nocturnal phenomena. They seemed quite disconnected. Moreover,
in the transference reactions I could see no reflection of this part of
his neurosis. After these nightmares and epileptoid phenomena had
continued for some time, I again asked the neurologist who referred
him to me to examine him again and expressed my suspicion of an
organic disease of the central nervous system. Examination was again
negative. I proceeded with analysis for another month and sent him
back for another examination. This time the neurologist told me he
had found unmistakable signs of a temperosphenoidal brain tumor.
He had an absent abdominal reflex and a Babinski on the right side.
ANALYSIS OF THE SYMPTOMATOLOGY Be
ie
The neurologist told me it was apparently a very slow growing
affair. Naturally I turned the patient over to the neurologist for
further care.
The purpose of demonstrating these various types of trauma is to
indicate generally the direction in which we are to look for an ex-
planation of the symptoms, that is, of the changes in adaptation. This
direction is obviously not the same as that concerned in the hysterias,
compulsion neurosis, or ordinary character disturbances. The simi-
larity between the reactions produced by pain, fatigue, a mild accident
without tissue damage, arteriosclerosis, brain tumor, indicates that
the province of adaptation involved has to do with the body (that
is, soma), with executive functions dealing with accommodation to
the outer world, and with those internal somatic organizations sup-
porting this executive apparatus.
Trauma, therefore, is an external’ factor which initiates an abrupt
change in previous adaptation. The particular domain involved is
that dealing with the outer world, and any function connected with
this aspect of adaptation can be involved. One way in which such an
adaptation can be interfered with is by actual injury to the bodily
part concerned (a limb or a sense organ) or to any part intermediary
to its functioning (injury to nerve paths). A traumatic neurosis is
a type of adaptation in which no complete restitution takes place but
in which the individual continues with a reduction of resources or @
contraction of the ego.
However, when such a trauma involves all the adaptive processes,
the result is death; but when only a portion of the total body ego is
involved, the necessity still persists to accommodate to the outer
world with those portions still intact or to some extent modified.
To illustrate this point, let us examine the change in adaptation
caused by the fracture of a limb. In this case, however, alteration of
the process of adaptation is so self-evident as to merit hardly any
explanation. The specific limb involved ceases to be effectual and in
fact ceases to be a part of the executive apparatus. When any call
is made upon this particular member, its activity must be deleted.
* The word external is not used as a spatial concept, for a brain tumor interfering
with neuronic pathways, though locked within the skull, is also external.
80 THE TRAUMATIC NEUROSES OF WAR
However, since most of the organism is still intact and since external
and internal stimuli continue to impinge on the individual, customary
tensions must be relieved. This must be done with the rest of the
organism taking up the slack created by default of one part. The
new adaptation is like the old in quality, except that, for example,
what the individual formerly did with the right hand, he now has to
do with the left. Thus we can say in this instance the quality of the
adaptation is not changed, only the executive technique. This is a
point we must watch, namely, whether or not the quality of the adapta-
tion 1s changed.
Some features of the actual injury to a limb we must note. The limb
is functionally useless. The musculature about the injury is in spasm.
Pain is present, and all posture and attitudes are designed to pro-
tect and immobilize the injured part. This immobilization is the first
step in a complicated healing process, which facilitates certain cellular
plastic processes with no relation to the conscious ego. The cessation
of function and immobilization are, therefore, one of the first steps
in the restitution.
In the case of a broken limb the change in the adaptive processes
is very easy to follow. But in the case of a broken adaptation—to labor
the analogy a bit—the restitutive processes are not so easy to follow
because we are led to suspect qualitative changes in adaptation not
present in the case of a broken limb. The principle of immobilization
produces clinical indicators which we call symptoms. This, for ex-
ample, is the case with muscular spasm in acute appendicitis or the
diminution of respiratory excursions in pulmonary tuberculosis.
Whereas we are under no necessity to examine further these im-
mobilization processes in internal medicine, for the concept “reflex
spasm” takes adequate care of these phenomena, the case is differ-
ent in the complicated trauma which involves highly complex integ-
rative processes including psychosomatic interrelationships. But we
are justified in singling out one series of unmistakable phenomena,
namely, those which correspond to the concept of immobilization.
This concept does not, however, do justice to the facts. A limb may
become immobilized, but a sense organ cannot. We must, instead,
therefore, use the concept of inhibition, which means that the func-
tion in question ceases.
ANALYSIS OF THE SYMPTOMATOLOGY 81
Exactly how an inhibition operates is not well understood now, but
we can assume that each organ will have its characteristic manifesta-
tions when its functions become inhibited. The relation of the organ
to the sensorium and its accessibility to voluntary control will surely
affect the manifestations of inhibition. The structure of the organ will
determine its manifestations. But most important of all, the function
may become blocked at any place along the line of its functional de-
velopment. This is a complicated process, consideration of which will
be deferred until a later chapter.
This concept of inhibition seems, however, to account for only a
small number of the actual symptoms recorded. It can explain only
the paralyses, the loss of consciousness, the sensory disorders, the
fatigue, the disturbances in motility. The other symptoms recorded
seem in no way due directly to inhibitions. However, we can expect
them to be at least indirectly related to such inhibitions.
In conclusion we may, therefore, say that a ¢rawma is an external
influence necessitating an abrupt change in adaptation which the
organism fails to meet, either being destroyed entirely by the external
agency or in part, and that this destruction may involve not tissues
but adaptation types. The predominant alteration of adaptation found
in the stabilized forms of the traumatic neurosis are inhibitory proc-
esses which can destroy the utility value of an organ or its functions.
The practical result of a trauma is, therefore, its interference with a
completed function as an executive weapon.
What we study, then, in the traumatic neurosis are the new adapta-
tions, which make up the bulk of the symptomatology. No individual
function can undergo interference without altering the adaptation of
the entire organism.
THE ALTERATION OF ADAPTATION
The clinical types described in the previous chapter show that the
alteration of adaptation, which we now call the neurosis in its stabi-
lized form, may place the emphasis in different directions. According
to the predominant symptom these traumatic neuroses can be thus
classified:
1. The simple restitution in the form of the repetitive tic or organ-
82 THE TRAUMATIC NEUROSES OF WAR
ized ceremonial. This is a truly remarkable qualitative change in
adaptation. The subject acts as if the original traumatic situation were
still in existence and engages in protective devices which failed on
the original occasion. This means in effect that his conception of the
outer world and his conception of himself and his resources as related
to it have been permanently altered. The symptom is periodic, but
the alteration in adaptation is constant, though its character may not
be conscious. One could describe this as a “fixation on the traumatic
event;” but this formulation does not tell us what has actually hap-
pened, though it has some descriptive value. The most highly organ-
ized form of the traumatic neurosis, the adaptive processes of this type
retain an advanced degree of purposiveness and organization. The
remaining types do not show any such traits.
2. The sensory-motor phenomena can exist in a highly organized
or disorganized form. Some types of sensory disturbances are ac-
curate hallucinatory reproductions of sensations originally experi- _
enced in the traumatic event. In this instance the symptom contains
the idea, “I am still living in the traumatic situation,” as we found
to be the case with the type described above.
Most other forms of sensory-motor disturbance are pure contrac-
tile phenomena—obliterations of functional portions of the ego. Oc-
casionally there are cases in which all sense organs ceased to func-
tion. In the paralytic phenomena no principle of selection could be
found, whether monoplegia, paraplegia, or hemiplegia.
Other types of motor disturbances involved neither limbs nor func-
tional units but activities, in the performance of which special diffi-
culties were encountered such as tremors, all varieties of gait dis-
turbances, and speech disorders. Cases in which paralytic phenomena
prevailed noticeably lacked irritability, aggressiveness, or typical
dream life.
3. [he cases in which the predominant symptoms were sympathetic
and parasympathetic phenomena are at times the original stabilized
form of the neurosis and at other times the tail end of a convalescence
from severer forms characterized by syncopal phenomena. The cases
in which autonomic disorders predominate have constant irritability,
sweating, tremors, tachycardia, and smooth muscle crises in every
ANALYSIS OF THE SYMPTOMATOLOGY 83
possible location. Their dream life is stereotyped and of the typical
catastrophic variety. Their sex life is impaired; impotence or di-
minished sexual interest, a constant feature. They are subject to fre-
quent episodes of confusion and intense vertigo. A diminished capacity
for sustained effort and easy fatigability are present; efficiency is
markedly impaired through general inhibitions to activity of any kind.
The autonomic disturbances often appear after a long period of syn-
copal phenomena. I have observed several cases of Graves’ disease
which arose after syncopal attacks ceased, but I have never observed
both together.
4. The group of cases characterized by syncopal phenomena shows
every possible variation from vertiginous attacks, confusions, and
fugues to loss of consciousness with and without convulsive phenom-
ena. I have seen nothing that resembles petit mal in these traumatic
cases. [he attacks are often provoked by external stimuli which resem-
ble the occasion of the original loss of consciousness. For example, a
patient who had been gassed would be thrown into an attack upon per-
ceiving any volatile oils, as in perfumes or gasoline, and no other
stimuli would produce an attack. Another patient had his seizures
only when his feet became wet. These cases behave as if their attacks
were finely conditioned reflexes. In other instances the “aura” of the
attacks is the repetition of the last sensory impression before they
originally lose consciousness—the sound of a barrage, the flashing of
an exploding shell, and so forth.
A very interesting point of orientation in these epileptiform cases
is the presence of anxiety. Generally these patients do not have any
great facility in projecting their anxiety; the greater the anxiety, the
fewer the epileptiform episodes. The symptom that stands in closest
relation to anxiety in these cases is irritability. Phobia formation is
completely unknown. Occasionally we encounter, not a projected
phobia, but a fear of the epileptiform attack itself, as we often do in
essential epilepsies.
From the standpoint of alteration of adaptation we can survey these
clinical types A) from the point of view of their organization; B)
from the point of view of the constant and variable features; and C)
from the point of view of the fabric of new adaptation, that is, are the
84 THE TRAUMATIC NEUROSES OF WAR
newer adaptation forms regressions in the sense that we have used
this concept in the obsessional neurosis and hysteria?
A. THE ORGANIZATION OF THE NEuROSIS
From the point of view of organization the type characterized by
compulsive rituals is one in which the adaptation of the individual
shows an organized effort at restitution by continuing the protective
devices used on the original occasion of the trauma. However, that is
not all. This evidence points very strongly to the fact that the in-
dividual is really in a continuous state of heightened vigilance and that
his conception of the outer world and himself have undergone con-
siderable change.
A second type of organization is to be found in the sensory-motor
disorders. In those cases characterized by hallucinatory reproductions
of sensations experienced on the original occasion, we again find the
constant feature that the conception of the outer world and com-
mand of his own operating resources have changed permanently. In
the case of the paralytic forms the new adaptation seems to be much
on the basis of those principles illustrated by a fractured limb. The
problem of adaptation is solved by casting out certain portions of the
ego permanently and rejecting them for use in the newly reorganized
ego. Therefore, although the individual’s conception of himself has
been profoundly altered, the change is apparently accepted completely
by the individual, and he continues to live on the same level of adap-
tation as an individual with his limb amputated.
A third type of organization is illustrated by those with periodic
syncopal crises. In these instances the problem seems to be solved
by retaining all functions at a diminished operative level with peri-
odic crises of complete contraction of the ego.
From the point of view of these three types of organization we can
now examine the symptomatology with the idea of finding out
whether or not all these symptoms have a serial relationship. This
brings us immediately to a question in connection with symptomatol-
ogy: What is a central and what is a secondary symptom? If, for ex-
ample, we consider a symptom like insomnia, depression, or amnesia,
we can conclude that these are all reactions of the personality as a
ANALYSIS OF THE SYMPTOMATOLOGY 85
whole to another situation which we must attempt to identify. Depres-
sion may be a reaction to diminished resources; insomnia, one of the
many manifestations of continued state of vigilance predicated by a
constant anxiety due to a new conception of the outer world or of
one’s own resources. [he amnesia is surely not a direct evidence of
damage but obviously a defensive process of the personality as a
whole.
Moreover, the real damage does not possibly always occur in the
form of a symptom, like a paralyzed limb, but by inference we can
understand the damage by examining the restitutive processes, parti-
larly those common to all the traumatic neuroses. However, one ex-
ception to this is the paralyses. Highly significant is the absence in
this type of all the evidences of tension and discomfort which charac-
terize all the other types of traumatic neuroses. This may be due to the
fact that the damage to the adaptation is complete but localized in this
case only. We are therefore justified in assuming that the real dam-
age in the traumatic neurosis is essentially an inhibitory process, that
this is the primary symptom, all the others being secondary.
This central damage may, however, be only partial in some in-
stances, Let us consider the contrast between mutism and stammer-
ing; the differences between complete paralysis, fatigability, and
weakness; vertigo and tremors; a localized permanent paralysis and
periodical losses and consciousness. If we regard the differences be-
tween these series purely quantitatively, then we are in a position to
group a large number of symptoms as secondary to this primary
cause. The whole irritability syndrome and the whole series of auto-
nomic (sympathetic and parasympathetic) symptoms group them-
selves as secondary to these partial inhibitions. However, these partial
inhibitions are always notably accompanied by symptoms of height-
ened vigilance and timidity, such as the insomnia and the catastrophic
dreams.
Our working scheme, therefore, is to make the inhibitory phe-
nomena nuclear and the others secondary to this primary change.
Thus far we have introduced one essential feature of the psycho-
pathology, namely, inhibition of function, and have predicated that
the remaining symptoms are manifestations of adaptive attempts on
36 THE TRAUMATIC NEUROSES OF WAR
this new basis. In addition to this we have introduced the idea that
inhibitions vary quantitatively, complete (paralyses) or partial.
Thirdly, in these partial inhibitions the resulting adaptations will
differ qualitatively.
B. ConsTANT FEATURES OF TRAUMATIC NEUROSIS
We now proceed to examine those features common to all the trau-
matic neurosis characterized by partial inhibitions, which include all
except those with motor paralyses. Such features are:
1. Fixation on the trauma—altered conception of self and of
outer world.
. Typical dream life.
. Contraction of general level of functioning.
. Irritability.
Proclivity to explosive aggressive reactions.
Ap wD
The one variable is the extent to which anxiety and apprehension
of situations in the outer world are consciously appreciated. Clinically
the observation is borne out that the more the patients are subject
to conscious anxiety, the less likely they are to have syncopal attacks.
This is an extremely complicated phenomenon, but the explanation
suggests itself that the existence of anxiety is an indicator of the ex-
tent to which the individual has resources at his disposal for escape
from and combat against the anxiety-provoking situation. Further-
more it suggests that those cases in which the syncopal phenomena
predominate are also those in which a repression-like defensive proc-
ess is operating—the function of such a defensive process being to
forestall or side-step the constant discomfort of the tension state
created by incessant anxiety. These patients are, therefore, less pro-
tected and hence more subject to complete ego collapse on the occa-
sion of certain crises. On the other hand, one may raise the question
in this point whether or not anxiety is of much value in warning
against a danger situation inescapable in fact—inescapable because the
only alternative is practically a complete cessation of life itself. The
reason for this is that the disturbed, inhibited, or blocked functions
cannot be substituted. This feature was also brought to our attention
ANALYSIS OF THE SYMPTOMATOLOGY 87
by the fact that displacement mechanisms so prominent in phobia
formation of ordinary civilian hysterias are practically absent in the
traumatic neurosis. One notes, for example, that the defensive rituals
described in the case on page 16 are not symbolic in character but
actual reproductions. Furthermore, those instances showing some
phobia formations are not characterized by elaborate and remote sym-
bolizations but by actual resemblances to the original situations which
provoked the neurosis. In other words, we do not find anxiety ex-
pressed in the form we find it in the ordinary phobias, but we discover
in its place another feature which points directly to the locus of these
partial inhibitions. This feature, irritability, consists of a constant ten-
sion state, a readiness for defensive attitudes on the occasion of any
sudden stimulus. We see, therefore, that the absence of both anxiety
and elaborate displacements serves to narrow down the probable locus
of the inhibitory processes. Moreover, a feature of the traumatic
neurosis is the nonaccumulation of new features with time, as in the
ordinary neuroses. The psychological fabric of the neurosis remains
very thin. This is also confirmed by the stereotypy of their dream
life.
If we regard the essential pathology as an inhibition and if we also
must assume that the individual continues to adapt himself to the
outer world with his diminished resources, then we can regard the
other features of the neurosis as discharge phenomena. At least this
is one way of looking at the disturbances of the autonomic system and
the syncopal phenomena. Before we examine these “discharge” phe-
nomena we can examine those features common to all these neuroses,
namely, “fixation on the trauma,” which merely means that the con-
ception of the outer world and the individual’s resources have under-
gone a change; the typical dream life; the sensory irritability; the
proclivity to aggressiveness; and the constant reluctance to activity.
Fixation on the trawmatic event. This concept of “fixation” was
introduced by Freud and after considerable maneuvering came to
mean an arrest of development. This concept “fixation” is useful in
the traumatic neuroses only to describe the fact that the effects of the
trauma have made a permanent alteration in adaptation but not neces-
sarily an arrest in development. It is barely possible we will eventu-
88 THE TRAUMATIC NEUROSES OF WAR
ally be able to detect such an arrest early in life, but at present we
have no means for locating this type of arrest. What is more obvious
is that the adaptation of the individual has undergone a change in
quality and organization.
It is notable in this connection that either the patient has a com-
plete amnesia for the trauma, the amnesias extending over the period
after the event and rarely for the pretraumatic period, although
such amnesias as the latter have been noted, or else the trauma is
remembered with many of the details missing, but the appropriate
affect is either completely absent, as in some epileptiform cases, or not
associated with the trauma at all. There is reluctance to think of the
trauma or of anything which resembles it. However, the effects of
the trauma are constantly active in the patient’s dream life. This am-
nesia is a crucial symptom. It indicates not merely that certain events
of the past were painful but that the effects of the trauma persist in
the form of an altered ego organization. The proof of this hypothesis
is suggested by the fact that when the pretraumatic ego organization
is restored, the amnesia lifts, as is the case in the ordinary neuroses.
The dream life. As we have said above, the dream life of the trau-
matic neurotic is one of the most characteristic and, at the same time,
one of the most enigmatic phenomena we encounter in the disease.
Unlike the dreams in transference neuroses the traumatic neurotic 1s
given to a strange stereotopy in his dream life. A special difficulty
confronts the investigator in attempting to study the dream life of the
traumatic neurotic. These difficulties are inherent in the nature of the
neurosis. The attempt to get associations to dreams is usually futile.
This is partly due to the general braking of all intellectual associa-
tive functions. Furthermore the dream, as a rule, only begins to say
something but never completes it. Instead of the condensation and
the compactness of action in the dreams of the psychoneurotic, we
have here a process of dilution and retardation, like the picture of a
normal piece of action slowed down by the motion-picture camera,
the film’s being cut off before the action is completed. The images
are redundant and perseverative.* Indeed amazing is to hear a patient
“This type of slow and perverse miscarriage of gratification is most prominent
in the comic, more particularly in what is known as slapstick comedy. The release in
ANALYSIS OF THE SYMPTOMATOLOGY 89
whose illness is nine years old state that night after night, with most
monotonous regularity, he has dreams which take him back to the
war scenes or which consist of feeble transformations of those battle
scenes. We reproduce here a series of dreams narrated by a patient
eight years after the original trauma.
1. I went somewhere, and we were discussing some things. After this
I went home. On my way home I was coming down the elevated stairs. I
dropped dead and rolled down the stairs. I woke with fear and found myself
almost out of bed.
2. I was talking to a few fellows about different things. I got into an
argument with one. I picked up some things and hit him with them and
killed him. I ran away and hid myself and woke up frightened.
3. I was at a party and a fight started. Someone began shooting and shot
me dead right through the head. I woke up frightened.
4. I saw my folks. They told me that my grandmother had just died and
had come to see them, and they asked me why I do not come to see them.
(Father and mother have been dead for three years; grandmother is still
living but is paralyzed. )
5. Someone threw a match into the cuff of my pants, and they started to
burn. I woke up scared.
6. I was on the Woolworth Tower and looked down, and as I did SO,
I slipped and fell to the ground. I made a hole in the ans and was
smashed to bits.
7. I was in a garden somewhere, and there were large roses, larger than
myself. I climbed up a ladder to smell them, when a large bee stung me on
the back of the ear, and I woke up with a sharp pain which lasted about half
an hour.
8. I was a keeper of a lot of birds in a great big place.
9. I was on the subway station. Someone pushed me off, and I was thrown
on the tracks. A train came along and ground me up.
10. I was in swimming and I was drowned.
these comedies is, however, laughter, because the victim is never hurt; in other words,
a successful overcoming of the trauma. Also to be remarked is that generally all mishaps
which terminate in disturbing normal upright posture—a man’s slipping on a banana
peel or even lesser accidents like a strong wind’s blowing a man’s hat off—always carry
a comic and ridiculous tone, thus provocative of laughter. The relationship between
laughter and fright reactions is very close in the infant. The comedian is interminably
shot in the pants, but he keeps on running; innumerable custard pies strike and smear
his face, but he keeps up the harmless combat. The explosive tension in slapstick laughter
is caused by the fantasy of triumphant invulnerability together with a deep conviction of
the falsity of the situation.
90 THE TRAUMATIC NEUROSES OF WAR
11. I was taken sick on the street with a spell. When I woke up you
were there to give me some medicine, and you told me to take it.
12. Somebody was sticking me with hot irons, and I tried to run away
from him and could not.
13. I was riding in an elevator in a big building. It went up so fast, it
went right through the roof. I was on a large boat with a lot of people, and
all were on one side of the boat. It capsized and we were all drowned.
14. I went up to see my aunt who has been dead for six years. It took me
two days to get there, and when I got there she was sick. She told me to get out.
(Patient’s association in this dream was that he was very fond of this aunt
and, that he used to go to visit her often.)
15. I was fighting with a lot of dead people, sticking knives at them, shoot-
ing them with a gun, but they didn’t do anything. They got scared.
16. I was fighting fish at the bottom of the sea. They got frightened.
We note that the most common content of the dream is the threat
of annihilation. The next type of dream in frequency is the aggression
dream, in which the patient himself is the aggressor but is usually
defeated.
These dreams are capable of several typical transformations. The
first of these may be called “the Sisyphus dream” or the frustration
dream. In this type the individual is usually confronted with a per-
sistent and unshakable frustration. Whatever activity he engages upon
is greeted with a certain stereotyped futility. Thus, the same patient
whose dreams were recorded above dreams also the following:
“T was in the room, and everything I touched or grabbed was turned into
sand. I put my hands in my pockets, and there was sand in them. I took off
my coat, and there was sand in it. Everyplace I looked I saw sand; every
place I walked, I was in sand. I tried to get away, but the harder I tried, the
deeper I would sink into it.”
Some time later the patient brought another dream of the same vari-
ety, but instead of sand everything turned into water, and he awoke
as he was almost drowned. Though the patient could not help me
with associations, the symbol of sand and water is typical for situations
in which fatigue sets in very easily.
From this type of dream to the next one is an obvious transition.
This second type of transformation may be called “the occupational
dream,” which has hitherto been described by MacCurdy and others
ANALYSIS OF THE SYMPTOMATOLOGY gI
in connection with neurasthenia. In this type of dream the patient
is engaged in an occupation, usually one in which he was engaged the
day previous; but instead of the work’s being consummated, the
patient encounters numerous obstacles and often awakens with dis-
aster threatening him. Thus a patient dreams:
I am in the yard while playing the water hose upon the flagstones. Water
stops running. After a while it begins again. Then the neighbor from whom
I borrowed the hose comes out and reproaches me, finally swears at me, and
then strikes me. ‘Then all the neighbors come running out, and they chase
me all over. Then I awaken in a sweat, feeling as though I had the life
pounded out of me.
The following dreams represent an interesting transformation of
the annihilation of the ego. The conflict is shifted from the threat
of annihilation of his body-ego to his means of livelihood. The pa-
tient, owner of a chicken farm in Long Island, brought the following
series, in addition to the usual annihilation dream.
“TI dreamed that I was on my, chicken farm and that I saw great big rats
eating up all my chickens.” “I dreamed I was in a rowboat and was riding in
my boat over my chicken farm,” to which the patient spontaneously made the
association: ““You know, chickens can’t swim.” “I was on my chicken farm,
but I noticed that the whole farm was covered with cement,” to which the
patient added, “Chickens need earth to feed upon; they can’t live on a cement
floor.”
In other words, where no threat of immediate annihilation occurs
per se, the threat is implied in the destruction of the patient’s means
of livelihood, The occupational dream is really a phenomenon of the
same sort, in which the means whereby the patient earns his liveli-
hood is being constantly frustrated. This is, of course, only manifest
content. They are dreams of frustrated dependency longings.
Although I could elicit no associations to these dreams other than
the few recorded, I think we are justified in pursuing them a bit
further. The dreams all say, “My means of livelihood is being de-
stroyed.” “I am separated from my mother”—hence birth or impov-
erishment dreams. But the affect of helplessneess, fright, does not
take an explosive form; it is attenuated and drawn out. Still another
interpretation is: “I cannot ‘eat’ the world,” in other words, achieve
92 THE TRAUMATIC NEUROSES OF WAR
an oral mastery over it. Most important to note in these dreams is
the oral symbolism and the absence of the anxiety-fright reaction.
I do not believe this a coincidence. This patient was much further on
in his convalescence than most traumatic neuroses I saw. He was
moderately well adapted, though this success was achieved at the
cost of a partial withdrawal from those stimuli in the outer world
which most annoyed him—noise, contact with people, and so on.
Hence he opened a chicken farm in a deserted section of Long Island.
From this mveau he is apparently able to begin to be interested in
the world again in an orderly manner, beginning with the oral zone,
the earliest type of mastery. These dreams are a record of this stage
of his recovery. One can begin to reinterpret the world by means of
one single interest, and such a stage represents a decisive step in the
reintegration of the ego. It indicates, moreover, the direction in which
this reintegration takes place and what occurred in the breaking up
of the ego.
These birth dreams, separation from mother (Weltuntergang,
annihilation, and frustration), indicate in a general way what took
place in the traumatic moment. The subject’s mastery of the outer
world ceases momentarily. In this moment he has been torn forcibly
from a hitherto friendly world. The re-establishment of the friendly
relations to the outer world may follow the same patterns as they
did immediately after birth.
The third form into which the annihilation dream may be trans-
formed represents a real transformation of the affect. These are the
guilt dreams. In these dreams the patient is engaged in some hostile
pursuit against some loved object, and he awakens from it with
the profound feeling of guilt.
The annihilation dreams are for the greater part responsible for
the insomnia of these traumatic cases. The patient awakens with a
feeling of relief and goes back to sleep again, this performance often
being repeated four or five times a night. Not infrequently he devel-
ops a defense against his dreams in that he is able to say to himself
in the dream, “This is not true,”? and lapses into a dreamless sleep,
or he awakens and finds the familiar evidence that it is only a dream.
I found this to be the case in several instances. The patients at first
ANALYSIS OF THE SYMPTOMATOLOGY 93
told me that they had no dreams at all, but on careful investigation
it proved that they had had nightmares every night, after which they
went back to sleep in a comfortable state of mind. In the morning
they had forgotten all about the nocturnal experience.
Are all these dream types related? It would seem so. I must recall
the dreams of my friend who was convalescing from a fractured skull
(see p. 76). His earliest dreams were annihilation dreams; then fol-
lowed combats in which he himself was out of danger—feuds, race
riots, and so forth, then more refined combats in the form of sports,
and finally the occupational dream which ended in frustration, this
last followed by one in which he said to himself: “My apprentice-
ship is over.” This man had thus during his convalescence all the
various types of dreams found in traumatic neuroses except the guilt
dream. There is reason to believe that this content varied with the
stage of convalescence, with the patient’s knowledge of this, and with
the re-establishment of his confidence not only in survival but in his
capacity for work. Yet, as we saw, the trauma did not give rise to
any of the permanent inhibitory phenomena found in the traumatic
neurosis; he was normally adapted to the external world. Thus he
did not have to fixate upon any inhibitions. Secondly, the convales-
cence was a complete form of abreaction. Thirdly, the constitutional
factor was missing.
These dreams furnish us with a most vital clue as to the locus of
the disturbance in the traumatic neurosis, and point towards the belief
that the idea of physical survival in the traumatic neurosis is also
connotable with the idea of work. All are forms of activity, aggressive
activity, means of mastering an enemy, or the forces of an environ-
ment, and so. WORK. We now begin to see why the traumatic neu-
rotic has inhibitions to work; the ego-organizational basis of work
has been undermined, and he now seeks militant methods of parasitic
existence.
We now come to the guilt dream, a type of dream I have encoun-
tered only in those with epileptic symptom complex. Stekel (87) and
Schilder (84) have also noted this dream in true epileptics. It is not
difficult to account for if we remember an observation of Freud’s in
“Das Ich und das Es.” (37) He says that the more an individual
poe eS 5
94 THE TRAUMATIC NEUROSES OF WAR
is obliged to repress his sadism, the greater is his proclivity for guilt
feelings. The guilt dreams show us, therefore, an immediate differ-
ence between the sadism directed to love objects and the sadism
directed to the outer world. In the one case we have a threat of anni-
hilation, in the other case a feeling of guilt.
From the dream life of these patients we can therefore draw cer-
tain conclusions about the nature of the conflict. What Freud says
about these dreams in “Jenseits des Lustprinzips” is undoubtedly
true: that the individual tries to abreact piecemeal the anxiety gen-
erated by the traumatic event. But in addition, several other points
are worth noting.
If we consider the dreams of the patient recorded on page 89 we
find that the dreams are concerned with certain actions and objects.
With regard to the actions, the dreams are all incomplete between
the initiated action and the objective—going downstairs, riding in an
elevator, and so forth. A constant fear is injected. Instead of the com-
pleted action, a threat of annihilation intervenes. This is the miscar-
riage either of his own ability or of the constancy of the physical laws
of nature. The action is always initiated and the objective in sight, but
it always fails. Why the action is undertaken need not concern us
at the moment. This frustration of the objective of a given piece of
action is especially prominent in the frustration of Sisyphus dreams.
One might say this represents an inhibition to complete the action.
True enough, but why the inhibition?
Secondly, the dreams of this patient concern themselves also with
the death or illness of women (grandmother and aunt) who are love
objects, very likely mother substitutes. Note the dreams of the man
who had a chicken farm. They seem to be a combination of miscarried
objective and death of mother (means of livelihood). In the guilt
dreams we have one additional elaboration; an aggression to the
object from whom one expects love and help, plus a fear of retalia-
tion by the object.
Thirdly, the only action that can be carried through is a wild and
ungoverned aggression; he annihilates or is annihilated.
These three types of dreams say essentially the same thing in differ-
ent ways; they all reproduce a helpless situation with its tremendous
ANALYSIS OF THE SYMPTOMATOLOGY 95
release of disorganized aggression. They all say, “I am as at birth,
I] perceive the world but can do nothing with it, hence it threatens
me.”
We can now go a bit further in the interpretation of the neurosis.
Some portion of the integrated ego is either destroyed or inhibited,
a portion which normally enables the individual to carry out certain
actions automatically on the basis of innumerable successes in the past.
This portion of the ego is injured in the traumatic experience, and
what results is an inhibition. This portion of the ego has, moreover,
a protective influence on the ego; these protective maneuvers we call
mastery or adaptation. Being deserted by these protective devices,
their psychic representatives, or those portions of the ego that have
taken over these functions originally exercised by such devices, the
subject feels deserted and obliged to face a world that must annihilate
him because he no longer has any defense against it. At least he has
lost command of the more highly integrated forms of defense against
it, and what remains is nothing but two primitive modes—violent
and disorganized aggression, or abject helplessness.
The irritability of the traumatic neuroses. From the point of view
of distribution, irritability is absent in no case of traumatic neuroses.
It concerns chiefly auditory stimuli, but in some instances there may
be sensitivity to temperature, pain, sudden tactile stimuli. These
patients cannot stand being slapped on the back abruptly; they cannot
tolerate a misstep or a stumble. From the physiological point of view
there exists a lowering of the threshold of stimulation; and, from the
psychological point of view, a state of readiness for fright reactions.
This is intimately connected with the general hypertonicity of these
cases. Auditory hypersensitiveness is most common, being the most
widely distributed sudden stimulus, ontogenetically the oldest sense
organ which establishes contact with its environment, and the most
intimately connected with fright.
Some question arises whether or not one can regard this auditory
hypersensitivity as a form of preparedness for anxiety or fright. These
patients, in response to sudden auditory stimuli, do not go into anxious
states, but into fright reactions. The responses are chaotic, at times
paroxysmal, and lack organization; after the reaction 1s over there
96 THE TRAUMATIC NEUROSES OF WAR
remains no residue of anxiety but only a heightened sensitivity to
the stimulus. It is not a displaceable anxiety but a reflex and is more
closely related to the syncopal reaction than to the displacement
phobia. Often the loud noise is the signal for an explosive violence
or a lapse of consciousness or, in milder cases, a state of general tremor
and fright. This apprehensiveness evidently cannot be converted into
hypochondriacal or phobic structure.
Possibly the inability to use this apprehensiveness in the form of
phobia depends on the content of the reaction and on its object. Anxi-
ety is a state of organized preparedness in which considerable time
lapses between the anxious state and the feared stimulus, but fright
is a disorganized and immediate response to an overwhelming stimu-
lus or one that appears to be such. Asa rule, no anticipatory fear of
either exists in these fright reactions to noise.
Sensitivity to other stimuli—light, smell, special stimuli like rain,
snow, and so on—are determined by the circumstances of the initial
trauma. Photophobia is rare as a general symptom. The sensitivity to
special stimuli has the character of a conditioned reflex; it is not a
learned, but an automatic reflex. The irritability also extends itself
as a diminished capacity to tolerate any stimulus, whether it be effort
of work or entertainment. An inability to fix the attention on any
given occupation, a distractibility, exists although the patients are
actually occupied with nothing.
From what has been said about irritability and the dream life, the
disturbance of sleep is easily one of the most constant features of the
traumatic neuroses. The increased susceptibility to external stimuli
prevents them from falling asleep; and when sleep is accomplished,
the dream content awakens them. A common form of disturbance is
the awakening during the hypnogogic state. The inability to cross
this threshold may occur six to seven times a night.
The tendency to aggression and violence. This is one of the most
common complaints of traumatic neurosis. Most patients have com-
plete insight into this characteristic, are troubled by it, and want relief
from it. It is, of course, intimately related to the irritability and hyper-
tonicity of the entire muscular system. The aggression may show itself
in the tendency to tempers. Easily aroused to anger, these patients are
very prone to motor expression. They either break or tear objects in
ANALYSIS OF THE SYMPTOMATOLOGY 97
these fits of temper or strike the people who happen to be around
them. This symptom is subject to wide variations. If the outburst is
accompanied by loss of consciousness, the patient is usually dangerous;
assault in this state is not uncommon. Often these patients injure
themselves unintentionally.
This feature of aggressiveness and violence is present in every
traumatic neurosis, irrespective of other symptoms; it varies, natu-
rally, with the severity of the neurosis, at times being nothing but an
occasional flare of temper. Most pronounced in the epileptiform cases,
it is also a conspicuous feature of true epilepsies, as we know. One does
not, however, find it to any extent in the physioneuroses of peace-
time, although one does find the irritability, particularly to noise.
Concerning the source of this aggression, we may find some clue
in the normal phenomenon of fatigue. A fatigued person shows, in
many respects, the same features of irritability and aggressiveness. A
fatigued individual has lost the capacity to analyze and to react ade-
quately to external stimuli. His reactions are then more primitive,
but the normal state can be restored with physiological rest. In these
traumatic cases the capacity for rest is disturbed, and in many ways
the reaction seems to be one of chronic irrecoverable fatigue.
The aggressiveneess of the traumatic neurotic is not deliberate or
premeditated. He never carries a trend. His aggression is always
impulsive; nor is it capable of being long sustained. Entirely episodic,
it often alternates with moods of extreme tenderness. One never finds
the aggressiveness and the impulsive violence without reactions of
tenderness. Thus, one soldier with a severe neurosis was stopped
one night by a street accident. He rushed to the injured person and
scolded all the bystanders for their negligence. At the same time he
was susceptible to physical pain to an inordinate degree.
The sadomasochistic complex is related to the irritability, the 1n-
capacity to analyze stimuli in the environment. Not found in the
physioneurosis of peacetime, this complex is present in the true epi-
lepsies in which, indeed, it is less controllable and subjected to a
large variety of checks and reaction formations.
The inhibitory phenomena. We would expect in the presence of
these violent outbursts of aggression to find inhibitions directed
toward higher and more organized forms of aggression. This is the
98 THE TRAUMATIC NEUROSES OF WAR
case. We find the outbursts of tenderness standing in relation to this
as a reaction formation. The inhibitions take the form of inaptitude
and lack of interest in work, fatigability, vertigo. Perhaps the tremors
and speech defects may be considered inhibitory phenomena. But
these latter two are more difficult to understand as inhibitions, espe-
cially the tremors which are so much bound up with irritability and
hypertonicity. Sexual impotence is not infrequent in these cases, and
when it occurs in conjunction with a picture of traumatic neurosis,
I prefer to regard it as part of this syndrome rather than due to purely
psychosexual conflicts. The existence of such in the presence of phy-
chosexual conflicts is easy to identify. Thus, one soldier who had such
symptoms of traumatic neurosis had an easily recognizable paranoid
condition with a repressed homosexual] trend. He was also impotent.
This regression to homosexuality did not appear to me to be caused
by his traumatic neurosis. It is difficult to conceive how this could
take place. Much more likely, during service his exclusive contact
with men in the army increased his efforts to repress this trend. To
conceive of an impotence that goes with the general repression of
sadism in the traumatic neurosis is not impossible.
We have seen from the irritability and aggressiveness and the
dream life that the disturbance lies in the relation to the outer world
and in those portions of the ego whose contacts with the outer world
are immediate and whose function is to master the environment. The
patient is, accordingly, inhibited toward the refined means of aggres-
sion expressed in work, the conversion of material into things, or
variations of this pattern. The vertigo and the tremors make it impos-
sible for him to continue to work; things fall out of his hands, he is
awkward and slow, it takes him a long time to accomplish a simple
task; the result is diminished interest in work and less gratification
in its performance. With this inhibition to work goes a decided lack
of enterprise and ambition. The patient is constantly obsessed with
fantasies which make him put up with the barest kind of existence,
makeshifts, and dependencies, provided that it relieves him from
the obligation of toil. In short, all forms of work are apparently
stripped of their gratifications.
From this approach the patient’s dependency on compensation is
ANALYSIS OF THE SYMPTOMATOLOGY 99
not difficult to understand. This feature does not, in any instance,
create the disease but appears rather as a logical and necessary out-
come of his inhibitions.
I have not been able to work out the characteristics of the tremors.
It would be extremely difficult to evaluate them psychologically. As
regards the vertigo, accurate descriptions help us to differentiate sev-
eral varieties. One form of vertigo is chiefly a locomotor disorienta-
tion; the environment rotates, moves, or makes perpendicular excur-
sions. Referred chiefly to the eyes, it is described in visual pictures.
Another form is described chiefly in kinesthetic terms and refers
almost entirely to the localization of the body-ego. These patients
describe their vertigo as an awareneess merely of the head. The rest
of the body seems to be floating in the air, “walking on clouds,” “can-
not find my legs,” and so on—a condition decidedly related to the
paresthesias and described by these patients as a part of their body’s
“soing dead on them.” Whereas these vertigos frequently arise in
certain situations, high places, very often the attack has no relation
to position or occupation. Most frequently the attack is provoked by
change in position, especially upon bending down.
In connection with the inhibitions of these patients, a word must
be said about the contraction of the intellectual field, very like the
contraction of the visual fields. The patients have a great reluctance
to think directly and consistently about anything, are distractable and
apathetic; but the interest in compensation is vividly maintained. This
is the only thing I have ever seen a traumatic neurotic really become
emotional about.
The sex life of the traumatic neurotic is not very different from the
rest of his behavior. Sexual difficulties never make the chief com-
plaint; in fact, they are never a complaint at all. One usually solicits
some information about it by questioning. The commonest symptom
is impotence in the form of aberrations of erectility, premature ejacu-
lation, but most often in the form of a lack of interest in the act or
in woman altogether. In view of the general character of the trau-
matic neurosis, this does not strike me as inconsistent. I get the gen-
eral impression from all these cases that their sexual development
has remained in a primitive stage. I regret that circumstances did not
100 THE TRAUMATIC NEUROSES OF WAR
favor a more systematic pursuit of this important aspect of the prob-
lem. Many factors resident both in the patient and the circumstances
under which I treated them rendered this research impossible. In this
respect the work has to remain incomplete.
We must note in passing that the affective tone in traumatic neuro-
sis is generally diminished, except for aggression and tenderness.
But these latter excesses are clearly the result of narcissistic identifica-
tion. The patient, incapable of joy, never laughs; incapable of sor-
row, never cries; is never overcome with any emotion, except when
his new sources of dependency are threatened, or when he identifies
himself with someone who is being hurt or threatened.
C. REGRESSION OR DIsORGANIZATION
Now we can approach the question of the character of the neurotic
reaction: Is it in the nature of a regression or disorganization? The
traumatic neurosis is characterized by the thinness of its psycho-
logical fabric and by the absence of those displacement phenomena
which make up the bulk of the material in a transference neurosis.
This absence makes us suspect that the material of this neurosis is
different in character from the transference neurosis. Up to a certain
point the two types of neuroses seem to be similar; judging from the
amnesia that usually envelopes the traumatic event, the work of
repression seems to be exactly like that in the transference type except
that it does not seem to involve idea systems nearly as much as it does
action systems. The repressed ideas are hidden from consciousness
and kept there by a powerful force; the repressed affects, however,
seem not to have the same leeway in the traumatic type; they cannot
be as readily displaced or symbolized, and even in the dream life
we find them invariably tied to the traumatic event. The repressed
affects, however, are associated with constant inhibitions, and the
blocked energies do find their way out again in a form not familiar
in the transference neuroses. The outburst of aggression in these neu-
roses does not have any resemblance to the process in compulsion
neurosis; in the latter, the aggression is organized and directed toward
specific relations to individuals; in the traumatic neurosis, much more
diffuse and disorganized. Another important difference lies in the
ANALYSIS OF THE SYMPTOMATOLOGY _ 101
methods both neuroses employ in handling the anxiety. It seems much
more difficult in the traumatic cases. In connection with the disposal
of the anxiety, the work of repression shows a departure from the
psychoneurosis. In fact, after a certain point the work of repression
seems to cease altogether, and the ego itself disintegrates from that
point on. We have already indicated that the conflict is about the
outer world and concerns certain specific instruments of mastery.
Let us first examine a case which has much in common with the
ordinary neuroses: |
‘The patient was thirty-three years old, fifth child of a family of ten, three
of whom were dead. His mother had died when the patient was nine
years old. This latter event, according to the patient, did not affect him
very much,
At the age of twelve the patient, who did not wish to live with his brother
after his father broke up house, ran away from home and became a mess boy
on board a sailing vessel. His schooling was interrupted at that time and was |
never resumed. He never learned a trade, although he had had a large variety
of occupations prior to service. Between his twelfth year and the present time
the patient had spent about three years with his father, worked for a while
as a sailor, then as a stove mechanic, and finally as a truckman, which occu-
pation he continued until he entered service.
Of his history prior to service nothing definite could be established but that
he had epileptiform seizures following an attack of diphtheria, which con- ,
tinued for an indeterminate period.* The character of his infantile convulsions ©
could not be ascertained and was probably denied because he thought it
would impair his status as a government claimant. His parental attachments
were not unusually strong; his reaction to his mother’s death was quite
normal. He was emotionally a rather shallow individual; he was never in
love with anyone, though he married after he returned from service a woman
many years older than himself. Toward her he was very ambivalent. As a
soldier he distinguished himself by extreme bravery in situations of danger.
When the patient was first seen, in March, 1925, his neurosis was seven
years old. It might, perhaps, be best to tell the story as he told it himself in
the course of treatment. When he entered the room he sat down rather stiffly;
the expression of his face was hard, immobile, and Parkinsonian, most lines
“The patient could not have had the seizures very often in service without being
discharged. This fact is important, however, since it shows that the patient had pro-
clivities for reacting with loss of consciousness. In view of the fact that the patient
was not a typical epileptic, this early history does not vitiate the merits of the case. For
purposes of this essay, the clinical diagnosis is immaterial.
102 THE TRAUMATIC NEUROSES OF WAR
of expression being obliterated. He answered in monosyllables and seemed to
have an attitude of defense. He volunteered no information and made no
complaints. In looking over his previous records, I noted that the patient was
suffering from spells of some kind. I proceeded, therefore, to make the usual
inquiries about his war experiences and the traumas to which he had been
subjected, At this point I began immediately to encounter a great deal of
resistance and anger. He explained his anger on the basis of an unwillingness
to talk about the war and especially about a certain event which had occurred
in service. This particular event, he said, was the starting point of his neurosis.
When his anger was abated to some extent and he was encouraged to talk
about it, anxiety set in. We see, hence, that it did not take very much to
uncover the anxiety underneath his superficial aggressiveness and his defensive
attitude toward the environment. At this point the patient became very
plaintive and pleaded for help, but insisted that concerning the traumatic event
he remembered absolutely nothing. The patient was then asked to describe
the fainting attacks or spells and every detail in connection with their onset
which he could recall. He said everything grew dark, and he sometimes saw
shadows in this clouded state. When asked to pursue the subject of shadows, he
remembered that on the night he was blown up he was crawling on the ground
on a scouting expedition, about seven o’clock, in pitch darkness, and that while
thus engaged, searchlights began playing on the party and caused shadows on
the ground. At this point the patient became very agitated and begged to be
relieved from further pursuit of the subject at that time.
His following appointment was two days later. He came about two hours
late and stated that for the past two days he had been in a constant state of
panic, that he hardly knew where he was, that he could not sleep at night,
that he was disturbed, that he had distressing dreams, and that he was afraid
to move out of the house for fear he would get an attack and have to come
up to the clinic in a taxicab.
‘This state of anxiety persisted throughout the greater part of the hour,
although, when the patient first came, his anxiety was slightly covered by a
series of defenses seemingly directed toward the external environment.
The task of recovering the traumatic event consumed a period of several
months but was never completely accomplished. After violent upheavals and
a great many distressing dreams, the patient would recall some little minor
detail in connection with the frightful event. All of this was exacted from him
in the face of persistent and violent resistance, in quite the same manner as
the hysteric struggles to bring out the details or interpretation of some pain-
ful experience. The difficulties he had in recalling these details of the trau-
matic event would sometimes result in an attack of vomiting, as if he wished
to vomit forth this foreign body buried in his mind. The spells came at varying
intervals, sometimes twice a day, sometimes after a remission of four or five
ANALYSIS OF THE SYMPTOMATOLOGY 103
days. ‘Ihe occasions on which he got the spells seemed to be such as resembled
or symbolized some detail of the original traumatic event. For example, he
would very often have a spell just as he reached the top of the staircase and
when he would enter a dark room. By the “spells” the patient intended to
describe a loss of consciousness not accompanied by convulsions—a syncope
without relaxation of sphincters but with occasional biting of his tongue and
grinding of his teeth. ‘This latter fact was evidenced by his many teeth broken
from chewing clothespins to vent the violent aggression during his attacks.
The oral character of his aggression is self-evident.
‘The loss of consciousness was always complete although occasionally more
like a petit mal and sometimes took the form of a fugue with an outburst of
violence. Of this latter type of spell, the patient described a state in which he
would seize any near-by object, his shirt collar or necktie or an article of
furniture, and proceed to tear or break it. On such occasions he has been
known to assault any person who came into his immediate vicinity or who dared
to touch him. On these occasions also he would chew his clothes and masticate
them into fragments. Formerly he was precipitated into these spells by any
sudden or persistent noise. The only aura which the patient had was a gradual
blindness and the seeing of shadows. The major spells lasted from fifteen
minutes to two hours, and he always woke up with a feeling of confusion and
disorientation followed up by a stuporous sleep.
‘The patient stated that he was a fearless soldier, never subject to anxiety
states during the war. The traumatic event took him entirely by surprise, and
at the first sitting he remembered nothing but that, confined in a straitjacket,
he woke up in a field hospital a long time afterwards. From his story it would
seem that for a few days or possibly as long as a fortnight, the patient had been
in an acutely agitated hallucinatory state. He would recall nothing more at
this stage of the treatment.
After the first few sittings the repetition mechanism was explained to him,
and insofar as it was possible, he was directed to see that the spells were repe-
titions of the original traumatic event and that in his original reaction he also
lost consciousness. Furthermore, he was told that all the auras he described
were hallucinatory sensory reproductions of the experience immediately preced-
ing the first loss of consciousness on the battlefield and that he was protecting
himself with all his might against any repetition in the outer world of the
original trauma and against any recollection of the event.
After the first few sittings then, the patient’s reactions were extremely
violent and distressing. This phenomenon has been observed by some other
authors, who state, therefore, that such a practice of permitting them to recall
the original trauma is wrong in these traumatic cases. With this view I cannot
concur, for this recollection is a means to an end. This attitude of alarm,
when the patient shows an aggravation of symptoms, speaks for a lack of
104 THE TRAUMATIC NEUROSES OF WAR
experience and an ignorance of the psychopathology of the disease. Any form
of anxiety that the patient expresses is, from the point of view of therapy, a
much more benign reaction than any of those which set in as a result of com-
plete suppression of the anxiety. Whereas the patient may complain and may
appear, for the time being, to be somewhat aggravated in his illness, the release
of this nuclear anxiety is the kernel of the therapy. One must not be alarmed
by it. ‘he patient’s immediate reaction was that he had seven spells within a
period of a week after his first visit to me; that he spent two sleepless nights;
and that, although he had been having anxiety dreams for the past seven years,
they did not compare in terror with those he had had since his first visit to me.
He then said that ever since the traumatic event he had suffered from
insomnia, from the typical anxiety dreams. The content of these dreams was
that something horrible was happening to him or that he was in the role of
the aggressor by killing some man and was punished as a result, or finally that
some person very dear to him was dead. Immediately after the treatment was
begun, the patient brought two dreams: “I dreamed that I was killing a man
and then that I was being electrocuted. I really felt the electric shocks going
right through me. I couldn’t sleep for a long time. Then I had another dream
in which I was murdering a man. The horror of these dreams was so great
that I had to get up and walk the floor until seven o’clock in the morning.
Then I tried to go to sleep again, but I was awakened this time by a dream
that the enemy was after me. Then I found I couldn’t sleep any more, and
during the following four days I had dreams in which I tore my hair and my
clothes.”
The remarkable feature of all this was that, together with a dependency
upon me for help, a vast amount of anxiety was released.
The dreams brought by the patient were that he was being tortured, killed,
persecuted by people around him with weapons, or that he was being annihi-
lated by the elements, that thunder and lightning were raging around him, or
that he was falling from great heights. He also dreamed that people to whom
he was much attached were being killed. This sometimes concerned his wife
and sometimes his father. ‘These latter dreams were extremely distressing, and
whenever he had one of this variety, the patient came with a profound feeling
of guilt and with the same kind of conflict found in the transference neurotics
when they discover their hostile wishes and death fantasies about some person
whom they presumably love. The type of dreams in which the patient was
the aggressor was usually the more distressing. In fact, one could hardly per-
ceive any difference in affect toward the dreams in which he was the aggressor
and those in which he was being annihilated. As we shall later show, the
dream of annihilation and the dream of aggression are complementary parts
of the same nuclear complex.
ANALYSIS OF THE SYMPTOMATOLOGY 105
A dream in which he was killing his wife obsessed him for days. After such
a dream he would walk around the next day crying, but he did not know
about what. When asked to associate with it, he said that his wife, the most
valuable person in the world to him, had helped him through all his difficulties,
and yet he had dreams of murdering her, of seeing her casket being carried out,
and so on. The guilt which obsessed the patient often took the form of hypno-
gogic hallucinations, in which someone, usually in uniform, would point a
finger at him and shout, “You killed me!” This type of experience would often
repeat itself several times during the same night. These aggressive dreams al-
most always brought associations about his mother. She usually was encouraging
him, advising him not to be afraid, and assuring him that she was in her
resting place. In association with these sadistic dreams, the patient mentioned
that prior to service he had frequent occasion to witness accidents. “This he
did with perfect equanimity; he had several times seen men killed in the
railroad yards, he saw a lion escape in Central Park from the Zoo, he saw
operations performed on animals; but he was never fearful.
Prior to the war he was never afraid of death; even now, when directly
questioned, he said that he did not fear death, but that he rather wished for
it as a release from his difficulties. He narrated, moreover, that before service
he was a gentle and agreeable person but that now he was always looking for
trouble, carried a chip on his shoulder, and was always ready to pick a quarrel.
This notwithstanding, the patient was very easily frightened by anything which
suggested fighting. If he chanced to be at a motion picture with a war scene
or a battle or a gun in action, he would go into paroxysms. Whenever a loud
noise occurred on the street, he either would be thrown into a panic, a
paroxysm, or would start running wildly for blocks at a stretch, finally ending .
up some alley. On one such occasion he ran for about ten blocks from the
original scene, then up three or four flights into a hallway, and landed, ex-
hausted, in a factory. This is very like the running amok observed among the
Malays. When asked why he ran, he said that he did not know, that he could
not stop running; it was, indeed, very much like the reaction of a frightened
horse.
The patient had several displacement symptoms. He feared going uphill
or downhill. We shall see presently that this going up- and downhill was
associated with the original trauma. He feared falling; he feared riding in a
subway train; he feared a collision or the train’s jumping the track. He was
mortally afraid of street traffic. When he came home and found nobody there,
he feared that there had been burglars in the house or that the house was on
fire. He feared diving into water or climbing a pole, both of which he had
done with bravado as a child. An important displacement was the fear that
somebody was following him on the street. ‘This did not have the character
7106 THE TRAUMATIC NEUROSES OF WAR
or the persistence of a paranoid delusion but seemed a part of his general fearful
adaptation to the environment, and he knew that these ideas of being followed
were imaginative. He did not take any of the usual paranoid defenses against
pursuit.
Concerning his minor spells, the patient often described phenomena of
transient blindness. ‘These he got most often when stepping out of a car or
a vehicle or out of a house, or when he would see someone being hurt. On
several such occasions he had to be taken home by some passer-by. Another
form his behavior took was fugues of violence, in which he tore bedclothes to
strips, chewed up clothespins, tore his collars, and struck people. Compulsive
and senseless laughter and nonsensical talk, of which he was entirely unaware,
were also the content of these spells.
As regards the original trauma, the patient did not, during the period of
observation, succeed in completely recalling and reconstructing the event.
_ With a great deal of effort, however, he was able to put together some of the
fragments sufficiently to indicate some of the conditions under which he lapsed
into the state of unconsciousness. His attacks of violence and transient blindness
were associated with the trauma. He was able to recall that it took place in
1918, twenty-three kilometers from Metz. He remembered also that he got the
command at seven o’clock in the evening, twilight being the time when he
got the largest number of spells. He remembered also being in very good
spirits. A short while after being given the command it was revoked. He
recalled stopping for dinner and having carrot soup. It was stormy and dark,
and shells were bursting around him. He climbed up a hill, then heard the
word, “Duck, duck!” This latter detail of being on the verge of an incline
and hearing the word “duck” recurred in several dreams. He also remembered
that the terrible night was Monday and that he woke up two days later in a
straitjacket, a considerable distance away from the original site. This was in a
dressing station. When the patient first woke out of his conscious state, he
said he was “like a rubber ball.” When anybody touched him he “would jump
sky-high.” Completely disoriented, he did not know his name, could not
walk, fell over objects, stuttered, vomited, and talked in a childish gibberish.
His reactions were those of a severely frightened child about two years of
age. He did not have any persistent paralysis. The whole world seemed to
be full of danger; he showed a trait very commonly found in these cases,
also in certain cases of epilepsy. He readily identified himself with anyone meet-
ing with an untoward accident. Thus, on one occasion, the patient was on
the street when somebody was struck by an automobile. He immediately be-
gan to run as though pursued by someone. He ran for blocks and then dashed
into a hallway, where he recovered enough to ask for some water. He was in
no danger at all; the other fellow was being hurt.
He recalled that, after being confined in a straitjacket for some time, he
ANALYSIS OF THE SYMPTOMATOLOGY 107
was released, whereupon he ran away. He did not know where he was running
nor why. He was caught and taken back to the hospital, where he said someone
tried to reassure him by showing him a dead man—a most inappropriate
piece of active therapy.
Concerning the original trauma, a few more details were uncovered. He
remembered that he was in the second line trenches; that a dud came over,
fell near him, and threw a great deal of mud on him; and that he was, in all
likelihood, trampled over by his comrades who were running away from the
dud. Many other details he could not unite with the original trauma, but, as
far as could be learned, the patient was not blown up by a shell. What had
probably happened was that he was given a command to go over the top,
which he did; that, as he landed in a second line trench, a shell came over
but did not explode, landed near him, and splashed him with mud; that in the
confusion he was thrown down and trampled upon by those around him.
Furthermore, the patient’s attitude toward work is notable. He could not
resume his former occupation, and all his efforts at rehabilitating himself in a
new occupation were unsuccessful. He had the typical attitude of inadequacy
to work. The accuracy of manipulation of his hands and fingers and his ability
to codrdinate them in any form of manual work were markedly impaired.
He described a phenomenon I have encountered frequently in the dreams of
traumatic neurotics, namely, certain days occurred on which everything would
go wrong, on which he was incapable of holding objects in his hands; he would
stumble over everything and would break things, very often to the detriment
of his employer. Extremely slow at work, he would labor for hours over
something which normally should consume only a few minutes. Needless to
say, the patient was able to bestow but little interest upon his working activities.
An interesting feature about this case was that the words most common in the
patient’s vocabulary were those describing combat and struggle. He was always
“fighting something through,” “winning something.” The successful accomp-
lishment of a task was described as “murdering it.” This is also an interesting
specimen of the perseverative tendency of the traumatic case and also of the
epileptic.
Thus, in the patient’s adaptation we see a tremendous battle against the
environment and a complete inability to exert a high degree of control over
part of his personality—that part concerned with the mastery of the environ-
ment, even in the form of a feeling of security or in the ability to perform
any persistent work. Accordingly he endured the frustrations impatiently;
impediments to the ease and comfort of his external existence were tolerated
with particular difficulty. He responded with exaggerated and disorganized
affect to physical hurt. Any trifling scratch or slight to his person would throw
him into a panic. He suffered extreme fluctuations of temper from great
violence and anger to maudlin tenderness. For example, he cried for three
108 THE TRAUMATIC NEUROSES OF WAR
days when he had to have his dog killed, and he melted with tears when he
witnessed a funeral procession. His emotional ties had a conspicuous poverty ;
but this impression may have been produced by his conflict with the external
environment which, for the time being, overshadowed his social relations
with people. All his reactions were either sadistic or masochistic. Moreover,
the patterns of his love life and social life were probably drawn from those of
his relations to the outer world.
After observation for about a period of five months his nightmares of sado-
masochistic content ceased, and he was able to sleep the greater part of the
night, and his spells had subsided to a large extent. The issue of compensation
was, however, a great obstacle to the cure of this patient. He frequently un-
derstated his improvement, for fear that if I reported him well, he would lose
his compensation. Thus, after an absence of seven months, the patient alleged
that he continued to have spells; but on inquiry his wife informed me that
he had not had a spell for five months. One must, furthermore, note that
during the early course of the treatment the symptoms increased in severity.
By that I mean his anxiety and distress became much more severe. ‘The capac-
ity for displacement, anxiety, and transference were the means of his partial
rehabilitation.
Most of the patient’s symptoms were reactivated on the occasion of a mild
trauma. One evening he was in a taxi which collided with another vehicle.
His old panicky reaction returned. All his symptoms, dreams, spells, and
secondary defenses recurred, He was in such a disturbed condition that he
had to be taken to Bellevue Hospital and kept there for several days. Prior to
this time he had had no spells, slept well, ate well, had ceased his vomiting,
was free from cardiospasms, and was becoming much less sensitive to noise.
This new trauma, however, did not have any lasting effect; after a short
period his condition was about the same as before discontinuance of treatment.
We must emphasize especially the existence of defects in the pa-
tient’s adaptation prior to the onset of his illness. They existed to-
gether with a pronounced poverty of achievement. He had many
vocational difficulties and educational handicaps. I was not able to
elicit, during the time of treatment, any reasonable account of why he
left home at an early age, except that it followed the death of his
mother and that he did not want to live with his father. His early
epileptiform attacks indicate already a marked constitutional factor
and the projection of the bulk of his conflict with the outer world.
When the patient first presented himself, we found a neurosis
with the following characteristics. The patient was evidently in severe
conflict which he had partly succeeded in repressing. The only idea-
ANALYSIS OF THE SYMPTOMATOLOGY 109
tional representation of the repressed material was to be found in
the conscious recollection of the trauma. Against this and against
any situation which resembled it, he directed all his energy. He had
almost a complete amnesia for the traumatic event and the reactiva-
tion thereof was met with the same resistance we encounter in the
transference neuroses when a deeply repressed factor is approached.
The content of the material which the patient was trying to keep
from consciousness was chiefly the traumatic event. This need not be
inferred; he was quite explicit about it. When his vigilance was some-
what relaxed as in sleep, he was disturbed by hallucinatory reproduc-
tions or faintly disguised and displaced representations of this experi-
ence.
He had several typical types of dreams: a) the dream of annihila-
tion; b) the dream of aggression with punishment; c) the dream of
cruel activities or hostile wishes against those whom he loved best,
associated with strong guilt affect.
In the dreams of annihilation he was awakened, as usual, by the
desire to evade the threat of extermination. In the dreams of punish-
ment we have a replacement of the aggression onto another object;
the aggression is now turned upon the patient himself. This is a com-
plicated phenomenon to be treated at length later. The hallucinations
of fingers pointing at him also belong in this category. In the third
type of dream the transformation of this aggression toward the love
object occurs with the accompaniment of intense guilt which is unbear-
able and tortures him throughout the day. To note the point at which
these guilt dreams occurred in the course of the neurosis is very
important. They were most persistent during the time when the pa-
tient made an active transference onto me and became dependent upon
me for help. Thus the patient is trying to repress an instinctive urge,
which to the outer world expresses itself as either aggression or fear
of annihilation but when directed toward his love objects, takes the
form of cruelty with the corresponding reaction formation of great
tenderness and pity. Thus, he cries when his dog dies.
What the patient expresses in the form of guilt to his love object
he expresses to the outer world as a fear of annihilation. The guilt
is, thus, the expression of the aggressive impulse directed toward
yA THE TRAUMATIC NEUROSES OF WAR
i
an object whom the patient needs for his protection. On the other
hand, the aggression itself is apparently caused by the failure of the
object (mother) to intervene between him and the hostile environ-
ment. In either case he feels helpless, and devoid either of resources
to master the world or of a protector who will do it for him, he 1s
justified in feeling the world to be a hostile place. This fear of the
outer world is really another way of indicating that he has lost the
means of mastery. Such a state of affairs we showed to be the case
in the dreams of a man who was suffering from a vascular disease
which he knew to be progressive and fatal (see pp. 77-78).
Hence the conflict in the annihilation dreams is, therefore, the
repression of the persistent urge to master the world, at least sufh-
ciently to be able to live comfortably in it, and the patient’s incapacity
to do so by virtue of the inhibitions initiated by the trauma. The
patient thus makes a compromise with the assumption toward the
environment of a passive attitude which cannot be represented in
another way than by annihilation. In his behavior toward the environ-
ment the individual has not the leeway that he has in the sexual
domain, where the repressed aggression takes the form either of
guilt or of the assumption of a feminine attitude. In this instance we
see a familiar phenomenon in the compulsion neurosis in which the
guilt feeling the patient has to his love objects is due to the expecta-
tion of being loved by those objects toward whom he has repressed,
however, a strong aggressive tendency based on the frustrations.
Hence the reaction formation in the guise of excessive tenderness.
But the passivity to the outer world cannot be thus elaborated. If
his aggression—by which is meant merely organized mastery—to
the outer world is inhibited, he can only remain in contact with it at
all by compelling it to maintain him without his own efforts, just as it
did when he was an infant. But then the entire outer world was en-
compassed in the mother. In this way he re-established, to a degree,
his shattered relations to the external world. The dependency upon
compensation 1s thus a defensive measure. By his infantilism he wants
/ to compel the mother to pity him and thus force her to take him to
| her again. His normal aggression to the outer world being blocked,
he reinstates a childish attitude of dependency on his wife, mother,
ANALYSIS OF THE SYMPTOMATOLOGY III
physician, government. That the trauma symbolizes birth in this
case, there can be no doubt; for under no other conditions is there
such a sudden release of aggression due to helplessness and so ex-
treme an attempt at mastery by way of the oral zone.
The inhibitions to maintaining a normally aggressive attitude,
which means just normal activity, to the outer world shows itself in
tremors, slowness of motion, vertigo, clumsiness, inability to hold
objects in his hands, spells, and so on. As secondary defenses against
this repressed aggression we see a reaction not unlike the feeling of
guilt. He defends himself against the onslaught to the environment
by a sensitivity to stimuli, by a rigidity to posture and motion, by a
complete disorganization of his responses, and by an attempt to
exclude the outer world by means of attacks of transient blindness
or spells of unconsciousness, in which state alone the patient is able
to carry out the mastery in the form of disorganized activity by break-
ing, tearing, smashing, and so forth. One must especially note the
tendency which this patient has toward oral destruction. He tears
objects not only with his hands, but he takes them into his mouth,
he grinds clothespins, he tears sheets with his teeth. All these defenses
cover up an anxiety which, however, remains accessible. This anxiety
is, par excellence, an indication of the amount of organization which
remains in the ego. We shall return subsequently to deal with this
problem at length. Whereas this patient’s anxiety is always at hand,
in other cases we find that the anxiety once present has completely
disappeared beyond resuscitation. Yet clinical symptoms exist not
unlike those described in this last case.
We can attempt to evaluate the pathological processes in this case
from the viewpoint of 1) discharge phenomena and 2) regression.
If we consider the aggressive outbursts as discharge phenomena, we
must first account for the tensions which accumulate. These give no
direct evidence. We know only of certain things which the patient
has lost the capacity to do. Can this be the source of the accumulated
tensions? They cannot possibly come from any other source. For these
activities are slow, gradual, integrated release phenomena which make
up the bulk of sheer existence. The evidence for their contraction
exists in the form of the lost aptitudes to work and activity generally.
1 i THE TRAUMATIC NEUROSES OF WAR
We can say, therefore, that these normal activities are organized,
integrated, and purposeful discharge phenomena which, being blocked
are now replaced by disorganized, purposeless, unintegrated activities
like discharge phenomena in appearance. So the problem of discharge
reduces itself to a problem of form, organization, and purpose. The
purpose is gone because the utility or pleasurable objective seems to
have vanished.
The question about whether these phenomena are to be regarded
as disorganized or regressive will be taken up later. Meanwhile it is
essential to recognize the difference between these phenomena and
those encountered in the transference neuroses. Here we find no slow,
gradually integrated use of a type of adaptation used in infancy, and
which yields gratifications similar to those earlier ones. If we predicate
a regression we must, moreover, be able to identify the infantile proto-
type. In infancy there is a stage of mastery which consists of tearing,
breaking of objects, prior to the development of dexterities which
extract a higher pleasure or utility value from the organized manipu-
lation. The child gets much satisfaction from these early activities.
One could, therefore, say that these disorganized aggressive phe-
nomena represent a regression. If so, it must be added that there is
no such gratification in the traumatic neurosis, because the utility of
the object and the utility function of the executive apparatus cannot
be exploited. It produces nothing but frustration. On the other hand
true regressive phenomena do occur in the acute phases of traumatic
neurosis. [his is illustrated by further material from the case described
earlier in Chapter II, page 54.
The patient furnished a retrospective amount of his experience immediately
after the trauma. Following his shock he was in a state of unconsciousness for
an inestimable amount of time. When he first awoke, he was not aware of
the existence of any individual part of his body. He first described it as a
“feeling of complete paralysis,” but this was not really the case. The fact is
that he had no body consciousness, but regarded his body as in infancy, a part
of the external environment; thus the whole series of integrations with which
the infant learns to identify parts of his body as appertaining to himself was
completely ruptured. Not only could he not move any of his limbs, but he
could not localize them; he did not have any idea of voluntary action, and
although he retained some degree of cutaneous sensations, he was unable to
localize it or to do anything to remove the source of irritation when it arose.
ANALYSIS OF THE SYMPTOMATOLOGY __si113
He remembers, on such occasions, being very uncomfortable, but he could
not tell on which side of the body the irritating stimulus was situated. That is,
in order to remove an irritation of the left thigh, he did not know how to turn
over on the right side. In short, voluntary motion was impossible because he
had lost all awareness of his body-ego. During this time he was incapable of
carrying out the simplest purposeful movement, including sphincter control.
This paralysis notwithstanding, a loud noise would throw him into a chaotic
response, during which he would sometimes fall out of bed. If it were possible
to have kept a complete record of his activities at that time, the patient would
undoubtedly have shown first the elementary body movements and would
have demonstrated the course by which they are synthesized into the motor
melodies making up most voluntary action.
With regard to the interpretation of stimuli coming from the outer world,
the patient was at first likewise impotent. He could not, in the beginning, dif-
ferentiate between the various forms of stimuli and reacted in the same way
to most of them. He remembers hearing noises but could not distinguish the
difference in quality of sound. The sound of a bell and the sound of a human
voice were more or less alike to him. He heard people talking, but he could
not understand what they were saying. His response to sudden noise was
very much lke that of a child—chaotic, incodrdinate, purposeless series of
movements.
He appreciated light, but he did not know the meaning of the objects in
the room as regards their usefulness. He remembers that he was able to dif-
ferentiate heat and cold; that he ‘was able to touch and to feel objects, but was
unable to grasp or hold them or to identify their use.
He could not swallow; he had to be tube-fed. He vomited most of the
time. Then spoon-fed for a while, he only gradually learned to put food
objects into his mouth. At first he did not appreciate the difference between
night and day and was entirely unaware of the passing of time. He was un-
able to interpret olfactory stimuli. It is interesting to note that the objects in
his room looked very different to him immediately after he regained con-
sciousness. ‘che patient was unable to describe just what he meant by this. But
judging from what several other patients have told me, he had no idea of
perspective, and objects appeared either confused or in two-dimensional form
or entirely detached from their meaning, as interpreted by the idea of use.
He was unaware of any relation to these objects; hence they were meaningless.
We can infer that his knowledge of spatial relations was completely destroyed;
this disturbance apparently involved not only a loss of the capacity to inter-
pret perspective—the knowledge of the motions of his own limbs in connection
with objects was also destroyed. The optical pictures of reality were nullified,
as were the optical pictures which must perhaps be associated with kinesthetic
sensations.
114 THE TRAUMATIC NEUROSES OF WAR
The patient gradually learned how to interpret external stimuli and to re-
integrate his body-ego. Voluntary motion was extremely slow in development,
and within a period of two months he was hardly able to get out of bed. When
he attempted to walk he found that his limbs would not support him. He had
a complete incoérdination originally, a complete astasia-abasia, and only very
gradually did he learn to walk and to execute codrdinate movements of varied
complicity. His ability to write was especially slow to return; in fact, the very
last to return. This entire process took several months.
While the patient was in bed, he remembers being subject to an almost con-
stant sensation of vertigo aggravated by changes in position, as when he was
turned or lifted. At these times the sensations were constant. He described
several forms of vertigo—a wavelike vertigo, a circular vertigo, and a lateral
vertigo.
After hearing repeated descriptions of his vertigo, I could not but feel that
what he was trying to describe was a loss of sensation of weight and of the
feeling of various parts of his body. Thus he would say, “I feel as though I
were walking on air.”
No fear existed in conjunction with this vertigo. This feature, vertigo, has
almost completely disappeared but does recur periodically just before and im-
mediately after his spells of unconsciousness. After his unconscious spells is a
mild recurrence of almost all the phenomena which occurred during his initial
hospital residence; that is, marked incodrdination, astasia-abasia, vertigo, a
period of mild dazedness, inability to intrepret external stimuli accurately.
I believe that this feeling of vertigo depends largely on the loss of kinesthetic
and visual pictures of the melodies of voluntary motion and is not, therefore,
a vertigo associated with the semicircular canals.
The patient describes his state of mind during his hospital residence as, “At
that time I could not think at all. I had no feelings.” The noteworthy feature
of all this is the interesting relationship between the development of the
thought process and the development of an integration of the body-ego.
We shall return to this case for the discussion of many issues. Suffice
it, at present, to say that, from the point of view of the genesis of
symptoms, the original effects of the trauma—the complete disappear-
ance of all the integrations which produce voluntary motion, that is,
the integration of the body-ego; the reduction of his capacities to those
of the newborn child; the gradual relearning process and reintegra-
tion of the ego and the periodic return to this state—are unique in my
experience.”
& + .
This patient was repeatedly demonstrated to classes in psychiatry at Cornell Uni-
versity, 1923-1928.
ANALYSIS OF THE SYMPTOMATOLOGY 115
Among the character changes which the patient described above,
the following is the most striking. Prior to his trauma he was hot-
headed, easily excited, and popularly known as “quite a scrapper.”
Especially interested in sports and mechanics, he was decidedly not
a bookish person. He was not introspective. Thought and feelings
did not interest or concern him nearly so much as things and activities.
He seemed much more interested in objects of the outer world than
in his mind.
Since his trauma he has tried to keep alive his interest in things,
especially in mechanics. However, he finds himself unable to con-
summate his interests. He is now no longer physically bold, but he
is keenly interested in devising labor-saving implements. This is the
only instance I have ever found in a traumatic neurosis of a construc-
tive use of a disability. He seeks now to make something which will
compensate for the wounded part of his ego. A labor-saving device
compensates for an awkwardness of exerting or an incapacity to exert
one’s own limbs. This is as close as one can come to the mechanism
of “sublimation” or refinement of the instincts of mastery. This easily
represents an attempt to compensate for his diminished capacity to
adapt himself to the external world. His fatigability, tremors, and
vertigos prevent him from doing any strenuous work.
Now, what takes place in this case is indeed a regression, but a
regression of the entire ego. The latter is disorganized in this case
to a degree which, we presume, exists at birth.
The regression may halt at certain phases of adaptation of early
childhood. McDougall has been able to report several such cases,
where the entire adaptation, method of locomotion, speech, manner
of eating, play with toys, behavior generally, regress to a period of
childhood, varying in different cases. I have not been fortunate
enough to see such cases. But the path of regression here is, as we
see, very different from the path of regression in the transference
neuroses. McDougall (62) described such a state in a patient who
became completely mute after his first bombardment. After a second
shock he behaved like an infant in every respect for about a year.
Unfortunately McDougall’s case contains no record of the patient’s
convalescence and no account of the symptoms present after he had
emerged from his infantile state.
116 THE TRAUMATIC NEUROSES OF WAR
When McDougall first saw him he described the patient as follows:
“He showed no trace of comprehension of spoken or written language and
uttered no sounds other than ‘Oh sis—sis—sis’; . . . he seemed to have little
or no understanding of the use of ordinary objects and utensils, most of which
he examined with mingled expressions of curiosity and timidity . . . when put
on his feet he walked jerkily, with short hurried steps, the feet planted widely
apart. As soon as allowed to do so, he slipped down upon the floor and crawled
about on his buttocks with the aid of his hand... . He could not feed himself
and was fed with a spoon by the nurse... . The expression of his face con-
formed to the rest of his behavior. .. . He slept soundly at night and during
the day would pass quickly, almost suddenly, from animation to deep sleep.
He wept like an infant when a nurse accidentally stepped on some of his
horse pictures and upon other similar occasions. He was sometimes playfully
mischievous. His digestion was easily upset; and if he took other food than
milk, broth, and slops, he would complain of pain in the belly, suffer from
wind, and would curl up in bed. He was very easily frightened. He shrank in
fear from dogs, furs, a negro patient, the stuffed head of a stag, and from all
sudden and loud noises the cause of which was not obvious. This timidity was
the main obstacle to progress; for on each occasion of being frightened he
relapsed to his completely childish condition and had to begin growing up
afresh. .. . After such relapses his progress was usually more rapid than before,
that is, he quickly regained most of what he had lost in the relapse.”
To recapitulate: The traumatic event creates excitations beyond the
possibility of mastering, inflicts a severe blow to the total ego organ-
ization. The activities involved in successful adaptation to the exter-
nal environment become blocked in their usual outlets. These activi-
ties are executive in character and take in the entire apperceptive and
executive apparatus, the sensory-motor, the higher intellectual cen-
tres, and the autonomic system. These activities are consummated in
some form of aggression. This aggression is expressed in every func-
tion of the sensory-motor apparatus and its adjuncts, the central and
autonomic nervous systems. This aggression is, moreover, capable
of infinite degrees of refinement and is progressive with the growth
of the child. The adaptation to the external world is the result of a
complicated series of integrations, which owe their existence in part
to the narcissistic gratification of success. As a result of the trauma,
that portion of the ego which normally helps the individual to carry
out automatically certain organized aggressive functions of percep-
ANALYSIS OF THE SYMPTOMATOLOGY 117
tion and activity on the basis of innumerable successes in the past is
either destroyed or inhibited.
The adaptation to this situation takes on various aspects in accord-
ance with different factors. A diminished capacity to exercise the func-
tions that can yield gratifications in the world exists, together with
a constant desire to have done with the world completely and, at the
same time, to adapt the self on a level compatible with these altered
resources. In the paralytic types (sensory or motor) such adaptation
is most successful and consists of an obliteration of only a portion of
the world, namely the offending part; but the rest of the world can
still yield its gratifications. This is really a negative form, autoplasti-
cally done, of mastering the world or rendering it harmless. The
patient throws away or sacrifices a piece of his ego, the introjected
world, to maintain a certain equilibrium.
The wish to have done with the world in many instances takes on
a phobic form, with the constant but ineffectual effort to re-establish
harmonious relations with it. This is affected by a regressive process
of a) making fewer demands on it, b) by re-establishing an infantile
relation to it. This means that the higher, more elaborate adaptations
are so inhibited while the more primitive ones are so reactivated that
in the end only two modalities exist: mastering the world or being
annihilated. The phobic character is emphasized by the higher invest-
ment of all seismic and sensory apparatus, irritability, and the lower
types of mastery, disorganized aggression. In this type the attitude
to the world is ambivalent, if one may so describe it.
In another type the wish to obliterate the world and to re-establish
amicable relations with it takes the form of a total obliteration of the
world episodically or periodically, in the form of syncopal attacks
and a renewal of the whole process of attaining from the beginning
gratifications from the world. The syncopal attacks not only symbolize
or enact death but also rebirth. The process of obliterating the world
is here complete as well as renewal of the whole process of adaptation.
TRAUMATIC NEUROSIS AND EPILEPSY
One final point needs elucidation: What is the relation between the
epileptiform types of traumatic neurosis and the true epilepsies? We
118 THE TRAUMATIC NEUROSES OF WAR
must, therefore, consider whether or not in genuine epilepsy there are
any more data as to what happens when certain functions of the ego
are incapacitated through an interference with their somatic basis
by an organic lesion, in contradistinction to the traumatic neurosis,
in which the interference seems to be a protective inhibition of the
psychic portion of these functions. To survey the literature on epilepsy
would in itself require a volume. We can review only the most
important contributions which touch on our own investigations.
Most epileptologists assume an organic basis for epilepsy, though
neuropathologists have failed to find constant or specific pathological
changes. This negative finding is of vast importance. If a great variety
of lesions can produce the same type of reaction, the reaction must
be a general one of the entire organism and not due merely to local
disturbance, whether circulatory (including, of course, the spino-
meningeal fluid), plastic, or metabolic. Neurologists have concen-
trated most of their attention on the neural paths of the discharge
phenomena. The four types of theory held by them are (55): a) that
the reaction is due to a summation of irritations, a theory based on the
Jacksonian syndrome; b) the release theory, based on the analogy
with decerebrate rigidity, that the inhibitory influence of the cortex
is removed (K. Wilson); c) the “short circwit” theory, which holds
that the explosive effect is due to localized interruption of association
fibres in the central nervous system; and d) the metabolic theory,
which asserts that the seat of the decompensation is in the cells and
is due to anoxemia, alkalosis, or anaphylaxis (Frisch). In addition,
there is Muskens’ theory that the epileptic attack is an elaboration
of the myoclonic reflex.
The clinical pathologist brings no new methods to epilepsy. Those
he uses are transplantations from internal medicine. His procedures
are therefore purely empirical. The findings are not constant, nor
do they have any recognizable relation to each other. Findings like
alkalosis or changes in salt metabolism in no way constitute direct
indicators of the pathology and are a dubious basis for anything but
symptomatic treatment.
The status of epilepsy in clinical psychiatry is rather ill-defined.
As a nosological entity it is isolated, and efforts to establish relation-
ANALYSIS OF THE SYMPTOMATOLOGY 119
ships or enlarge the concept of what constitutes an epileptiform reac-
tion are based entirely on descriptive resemblances. Vagus attacks
and migraine on the one hand, and on the other, contradictions of con-
sciousness due apparently to emotional disturbances, have been con-
sidered epileptiform manifestations. [Kleist (53), Jelliffe, Bon-
hoefter, Bratz. |
A psychological approach to epilepsy is justified nevertheless not
only if we grant the possibility of its organic nature but even if we
accept as a premise its determination by organic, that is, plastic or
metabolic, changes in the central nervous system. This premise of
organic determination does not explain the effects of the condition
on the personality as a whole, nor does it cast any light on those crises
which unquestionably arise from purely psychic stimuli. Further-
more, even if we assume that the basic factor is organic, we cannot
use this fact to account for the changes brought about in the individ-
ual’s adaptation in any direct manner. If a defect is present at birth,
we have a right to assume that it will greatly influence the entire
development of the personality. An organic defect in the light of
psychology can only be regarded as a special form of interference
with certain executive weapons of the ego which influence the ease,
speed and effectiveness of adaptation. In the traumatic neurosis we
have demonstrated that the use of these weapons may be inhibited
by purely psychic factors, But even an organic lesion must have certain
definite characteristics before it can give rise to epileptic symptoms.
The epileptologists agree (see Frisch, 40) that it must be located in
certain convulseogenic areas.
A well established fact is that not all organic lesions of the central
nervous system give rise to epileptic symptoms. We can, therefore,
accept the organic as a basis of essential epilepsies, but we must evalu-
ate it as only one type of interference with the executive functions of
the ego. Such interference, owing to the peculiar interplay between
anatomical structure, the uses to which it is put, and the drives it
satisfies, may be of a purely psychic fabric. This can be proved by the
empirical result of therapy on post-traumatic epilepsies. Such inter-
ference, organic or psychic, cannot but make a severe disturbance in
the instinct life of the individual.
120 THE TRAUMATIC NEUROSES OF WAR
The psychoanalytic literature on epilepsy suggests various avenues
of approach. The formulations of Clark (14) are based on the Freud-
ian conception of schizophrenia. The special characteristics of the
epileptic which, he asserts, antedate the seizures themselves and may
be present from birth, he designates as “epileptic narcissism’—“an
excessive reaction formation against all previous traumas, birth,
breast, bottle, diaper, and so on.” The seizure itself is a regression
to “metroerotism,” its economic purpose the repair of the damage
done by the trauma.
These formulations say nothing that is essentially untrue; their
defect lies in the fact that they dress descriptive psychiatry in psy-
choanalytic terminology. A dynamic relationship between the so-
called “epileptic character” and the theory of narcissism is nowhere
demonstrated. The path of regression is nowhere described and one
is obliged to ask the question why one narcissistic regression should
lead to a schizophrenia and another to an epileptic reaction.
Stekel’s (87) work on epilepsy contains some very important con-
tributions. The content of the epileptic seizure, he finds, may be a
crime, a forbidden sexual act, a punishment by God (and thus a sym-
bol for death), or a repetition of the act of being born. Stekel notes
the importance of infantile traumata for the development of the
epileptic reaction; the epilepsy forms successive protective layers
about them. He lays great stress on the aggressiveness of the epilep-
tic, the tendency to rage, hatred, and violence, combined with a
heightened feeling of guilt and reaction formations against these
tendencies—the excessively affectionate platitudes and religious affec-
tations. If the epileptic relives a traumatic event in a spell, the spell
becomes more pleasurable. Stekel makes an effort to account for the
disposition of the aggressiveness but fails to give any account of its
origin. It is, therefore, part of the “character.”
Schilder’s (84) work is a decided departure from that of Stekel
and Clark. He is of the opinion that epilepsy is an organically deter-
mined syndrome. In his studies on postepileptic twilight states, he
notes that the fantasies deal with ideas of destruction and rebirth, the
latter being bound up with crude sexual formulations. These fantasies
may be projected in the manner characteristic of schizophrenia, as a
W eliunter gang. Schilder notes a compulsion to activity, a subjective
ANALYSIS OF THE SYMPTOMATOLOGY I21
maniacal experience at the end of the twilight state. He places a
different construction on his observations than do Clark and Stekel,;
the content is interpreted as a representation or projection of those
biological changes associated with the experience of the seizure itself.
Furthermore Schilder (84) notes the marked apperceptive disturb-
ance in these twilight states. This he interprets as an effort for a more
complete understanding of the outer world. In the twilight states
libido has been withdrawn from portions of the perception ego. He
sees in epilepsy a return of the confluence of body and world. There
is a persistent wish to have done with the outer world altogether, a
tendency checked by the libidinal ties to it. He notes the perseverative
tendencies. The bigotry and righteousness are reaction formations
against the desire to overwhelm the world. The speech disturbances
are like the aphasias; the word withdraws itself not only as word idea,
but as word form. The epileptic’s social life, guided by the ego ideal,
is patterned on the relations of the ego to the external world. This
ego ideal is fortified with narcissism.
Freud has said comparatively little about epilepsy. In The Ego and
the Id (37) he has one sentence: “We perceive that for purposes of
discharge the instinct of destruction is habitually enlisted in the serv-
ice of Eros; we suspect that the epileptic fit is a product and sign of
instinctual de-fusion; and we come to understand that de-fusion and
marked emergence of the death instinct are among the most note-
worthy effects of many severe neuroses, e.g., obsessional neurosis.”
In Dostojewsky und die Vatertitung (39) Freud deals with the
criminality of the epileptic. Dostojevsky’s choice of material is an
indication of his criminality. His destructive tendencies are turned
upon himself in the form of masochism and gwilt. Freud is of the
opinion that epilepsy may arise from somatic conditions and from
psychic ones, such as fright. The mechanism of abnormal instinct dis-
charge may arise from a disturbance in brain function, or from an
inadequate mastery of psychic economy. In both types of origin he
sees the similarity of the underlying mechanism of instinct discharge
(Triebabfuhr). Freud believes the epileptic reaction to be the expres-
sion of a neurosis whose characteristic is to discharge through somatic
channels masses of excitation which cannot be mastered psychically.
122 THE TRAUMATIC NEUROSES OF WAR
Freud (39) in this article shows us how the epilepsy is brought
into relation with the Oedipus complex, how its content (death) is
a punishment for the fantasied murder of the father, and how, in the
case of Dostojevsky, the epileptic satisfies his guilt by a persistent and
ineluctable masochism. These observations can be verified on any
epileptic. However, these observations of Freud are concerned chiefly
with content, whereas the essential problem in psychopathology here
is one of form, especially so since the content is the same as in other
neuroses.
The uses to which the epileptic puts his symptoms does not, how-
ever, solve the problem of their highly specific character; nor does
it tell us why he has his epilepsy and not a compulsion neurosis or
schizophrenia. We cannot be dealing merely with the quantitative
problem, namely, that the aggression in epilepsy is greater than in
compulsion neurosis. The epileptic manifestations are brought into
closest relation with every aspect of the psychic life of the subject,
and from this we must assume that the epileptic basis was present dur-
ing the time these constellations were formed and in all likelihood
influenced their particular character. We can bring evidence from the
traumatic neurosis to bear on this question. The “epileptic character”
is acquired by patients with this neurosis after the trauma; the trauma
struck a completed organism without time to weave it into all the
libidinal relations with the world. The aggressiveness of the person
with a traumatic neurosis has the same fabric as that of the epileptic;
but for all that, we do not see it turned upon love objects or trans-
formed into masochism and guilt. In the traumatic neurosis this
ageression has not come under the influence of the superego. In this
neurosis, moreover, we were led to believe that the apparently enor-
mous increase in aggression was related to the impairment in ego
functions which have already lost their usefulness.
In the psychoanalytic discussions on epilepsy the attempt is usually
made to account for the symptoms on the basis of the libido theory.
That is, the individual’s development is traced as regards the distri-
bution of the sexual impulse in the face of social discipline. This is
no differential feature and hence such descriptions can only tell us
how the particular epileptic in question handled this phase of his
development; but it does not tell us anything about the epilepsy itself.
ANALYSIS OF THE SYMPTOMATOLOGY 123
The specific pathology of epilepsy must be sought elsewhere than
in the development of the sexual instinct. The concepts of the libido
theory are not geared to deal with the phenomena that are apparently
specific to epilepsy.
For the purpose of allocating the essential disturbance in epilepsy
the study of the following case might be useful. The features to be
watched are those which indicate faulty development of mastery
techniques. :
The patient suffered from seizures, both grand mal and petit mal. She was
thirteen years old, well developed for her age, and had no physical defects.
She was the fourth child of a family of five, all the others being entirely
well, Her family history was negative. Her mother was quite confident that
ever since infancy the patient had shown herself to be different from her other
four sisters. Although the mother had borne five children, she had suffered
during the gestation period with none but the patient, at which time she had
had a mild toxemia of pregnancy with gastric symptoms, general irritability,
and “nervousness.” This pregnancy occurred, moreover, during a time of
considerable external stress, for her husband had been out of work for a
long time.
Labor was not difficult, delivery being without instrumentation. The patient
was not breast-fed at all but bottle-fed for a long while. Weaning was exceed-
ingly difficult and effected completely only at three and a half years of age,
the last six months of which were occupied with rubber nipple sucking. “The
patient was an exceedingly active child, constantly moving and fidgety and
very early in life showed a tendency to violence, first in the form of biting
and later of striking and beating any offender. She was also exceedingly mis-
chievous and destructive. One of her favorite pastimes was boring holes into
the plaster of the walls.
She began to talk at six months and walked at eleven months. During the
first years of her life she had great difficulty with her diet. She suffered from
colic and constipation persistently for years. She never had convulsions in
infancy or early childhood in connection with colic or teething. Control of
sphincters was attained with no great difficulty. Her intelligence was good, in
fact, precocious.
Of her character prior to the onset of her illness, the patient’s mother states
that from early life she had shown traits which persisted in a more intense
form. She was very restless and showed overactivity of the entire muscular
system, a condition which her mother believed responsible for her frequent
falls from highchairs and hammocks. At six months she had fallen from a
considerable height and was speechless for a long time. Such falls were fre-
124 THE TRAUMATIC NEUROSES OF WAR
quent. Her mother noted no such proclivity for falling in any of her other
four children. In sleep as well as in waking hours, she was restless.
She had always been an exceedingly jealous, fighting, sensitive, and selfish
child and extraordinarily fearful of physical pain. The sight of the merest
scratch, pinprick, or stick of a knife or needle would evoke extreme pallor
and trembling, and recovery was slow. A very pugnacious child, she found it
difficult to forgive or forget anger and injury. She was particularly exacting
about neatness and cleanliness of her clothes. In her games she always had to
be the winner and could not tolerate being pronounced wrong on any occasion.
She was not, however, the kind of child who ran to mother to have her wrongs
righted; she was not as dependent on maternal affection as the other children.
Tantrums and violent tempers were frequent on insufficient provocation.
The circumstances under which her illness appeared were as follows: One
year prior to her first visit to me she was subjected to what will readily be
conceded a traumatic event. One of her friends owned a bulldog who often
played with the children. One day the patient was playing with the dog’s
owner, who in fun “sicked” the dog on the patient. Frightened and with the
dog barking at her heels, she ran through the hallway of her house, up four
flights of stairs and down again, and all out of breath landed in her apartment
in a state of collapse, pale, palpitating, and speechless. Her mother investigated
the incident and learned that the dog was a friendly dog, probably excited by
the patient’s running away.
Immediately after, the patient began to show signs of a disturbed state of
mind. Her sleep was interrupted by distressing dreams of being chased by a
mad dog, from which she would often awake continuing the dream in the
form of a hallucination. She would wake the household with her loud screams.
The content of these dreams changed. Sometimes someone was going to
steal her: “I was going to die.” “Terrible things were happening to me.”
Sometimes she hallucinated dogs at night. During the daytime she feared
dogs, but she did not flee from them. She trembled on seeing them.
The mental disturbance immediately following the traumatic event con-
tinued, and within three or four days after the fright she fell into a swoon
without movement or convulsions. From that time until one year later she
was subject to petit mal attacks to the extent of five to ten a week. Then she
began to have grand mal seizures, all nocturnal, about two or three weekly.
The grand mal attacks came in clusters, with long remissions.
The character and behavior changes which ensued with the onset of the
petit mal attacks were exaggerations of traits existing prior to the trauma but
which now took on a vicious and more intense form. The terrifying dreams
continued with the same content. As a result, she developed a defensive in-
somnia which kept her awake three to four hours after bedtime. When she
slept, she was very restless, tossing and kicking, easily awakened. Occasionally
ANALYSIS OF THE SYMPTOMATOLOGY 125
she would remember the dreams preceding the grand mal attack; they were
of the usual terrifying character. She became exceedingly sensitive to sudden
stimuli. A loud noise, unanticipated, would shock her; someone calling her
name suddenly or touching her from behind had the same effect. Changes of
bodily position, such as bending down and getting up, or getting up from a
reclining position, were accompanied by dizziness. Vision was often blurred
in transitory fashion. (This was subsequently learned to be a self-induced
state, accomplished either by voluntary pressure on the eyeballs or burying her
head in a pillow upon awaking.) This illustrates the principle of the utiliza-
tion of a handicap for the premium of pleasure. It always took her a little
while to acclimate herself to her surroundings immediately after waking up.
Looking persistently at an object would often make her dizzy or induce
diplopia. Her dizziness she described as “seeing waves on her side.” ‘This
meant that the objects looked at had a wavy motion, particularly on the outer
rim of her visual field. Looking persistently at a light made the light grow
progressively larger.
In addition to this state of irritability to external stimuli in the environment,
her motor reactions became more intense but not directed toward any special
stimulus. She was constantly fidgeting, crossing her legs, uncrossing them, biting
her nails, shifting her position, standing or lying down, moving her hands,
tapping, swinging her legs, knocking them against each other, and so on.
Her temper grew progressively worse and the tendency to motor expression in
the form of shouting or striking grew more pronounced. She became more
quarrelsome and selfish and unable to admit herself in the wrong or to admit
a fault.
Her mother noted a most important change in her character. “A... . was
much more grown up before the fright than she has been at any time since.”
Until the fright she had been interested in schoolwork and was able to con-
centrate and learn everything easily except arithmetic. After the fright and
the ensuing epileptic symptoms, she had a distinct reversion to earlier types of
interest. She gave up learning, both her schoolwork and the piano, and re-
verted to activities discontinued two years previously, such as playing with
dolls, jacks, and checkers. These now became her chief interests. She was
always distracted, and her attention was difficult to engage. Fairy tales were
her preference rather than books of adventure or romance.
In regard to the petit mal attacks and their provocation, the following
history was obtained from the patient and her mother, They often recurred
without special provocation and without special relation to the current cir-
cumstance or her reaction to it. However, the petit mal attacks were appar-
ently more frequent when she became distracted and when her attention was
disengaged from external situations. Concerning spells of this character, no
amount of questioning could elicit any indication of the nature of the thoughts
126 THE TRAUMATIC NEUROSES OF WAR
or fantasies that initiated the attack. Usually she would have no recollection of
having had such an attack.
She was, however, able to recall petit mal attacks which seemed to be re-
sponses to a given external stimulus. Persistent efforts of attention would often
result in an attack or in an abortive attack indicated merely by a transient
dizziness and a sickening, nauseous sensation in the abdomen, followed by
belching. More often the spell would occur apparently as a reaction of in-
adequate motor discharge and mental elaboration (transferability) of an emo-
tion. The most common occasion was anger. She would often pass from a
state of intense anger into a petit mal attack, preceded by dizziness. During
the spell she would be completely impervious to external stimuli, her limbs
would stiffen slightly, her hands usually would turn to the left automatically,
and her eyes become glazed in a stare. After a few seconds of this she would
be dazed for about a minute or two and usually lose the trend of what engaged
her attention prior to the spell. During these moments she was extremely
uncomfortable, restless, yawning abundantly for one or two minutes. The
following incident was the occasion of a petit mal attack. She was always
particularly exacting about how her dresses should fit. One morning the sash
of her dress was tied in front, where it rubbed against her kneees as she walked.
This irritated her exceedingly, and she told her mother about it; and her
mother suggested that she tie the sash in back. The child insisted it be tied on
the side. Her mother opposed her wish. She became angry and had a petit
mal, meanwhile forgetting all about the sash. When I questioned her, she said
she had become very angry and wanted to hit her mother, “but instead of
hitting her I got a spell.”
After I had learned something about the situations which provoked the petit
mal attacks, I deliberately set about to create such a situation artificially
through the use of her transference to me. An occasion presented itself one
day. She was asked to tell me what had occupied her during the two days
intervening between visits. She told a very casual story of eating, sleeping, and
playing. Her mother indicated to me that she had omitted some important
event of the last few days. A. . . . persistently denied that anything else had
occurred. Her mother then volunteered that A... . had had a violent quarrel
with another girl somewhat older than herself. When asked why she omitted
this incident from her account, she said that she knew quarreling was wrong.
She then said that she was marking up the flagstones in front of her house with
chalk, when the janitor’s daughter, fourteen years old, came out and ordered
her to stop. A. ... insisted for one reason or another that she was justified
in continuing her game. I decided on this occasion to scold her soundly,
telling her that she was in the wrong, that the other girl was right in making
her stop the game, that she ought to know better, and the like. All this was
said in an angry tone. She lay on the couch speechless and forthwith had a
ANALYSIS OF THE SYMPTOMATOLOGY 127
petit mal attack, out of which she came making grimaces at her mother,
evidently completing her vengeance upon her for telling me about the unfor-
tunate incident. After she had sufficiently recovered from her petit mal, I
apprised her of what had happened and asked her to tell me what passed
through her mind as I scolded her. To this she could not reply, except that
she “didn’t feel very good,” and no amount of encouragement would induce
her to abreact upon me any of the anger she had tried to repress. However,
the events of the following day indicated that my scolding had made a pro-
found impression upon her. [wo days later her mother came with two bits
of news: ‘The first was that during the past two days A... . had been better
behaved, less irritable and quarrelsome, and more obliging than at any time
in years; the second was that she had had many petit mal attacks and two
grand mal attacks and that upon waking out of the last one the morning of
the visit, she complained bitterly to her father about me. She told him how
rude and cruel I had been to her and justified her conduct to him.
I then explained to her that I had scolded her deliberately to teach her
why she had these petit mal and grand mal attacks, that I wanted to teach
her other ways of reacting and called her epilepsy by the name of a “bad
habit.” I assured her of my deep interest in her and that I was wholly bent
on doing for her what was best. With this reassurance, she proceeded more
willingly to tell me of her feelings towards me during the past few days.
At first she was rather timid and stated that when I had scolded her “she
didn’t feel so good;” then she remarked that she couldn’t forget my angry
voice for a long while, that she had thought about it and been angry at me all
day and had fantasied beating me. When asked why she had not called me the
names she subsequently thought of and why she did not actually beat me, she
replied that she could not possibly do that, since at the time she could not
think. She was evidently dazed by my rebuke and took refuge in her petit
mal. After this reassurance she left in a friendly mood, after communicating
to me many things she had previously tried to without being able to bring to
mind.
Her grand mal attacks were all nocturnal and took place in the hours
between 5:00 A.M. and 7:00 A.M., most of them at about ten minutes of
5:00 A.M., a time corresponding to the milkman’s rounds. ‘There would be
a generalized convulsion, with frothing and tongue-biting but no relaxation
of sphincters, followed by marked dyspnea and choking sensations, During
the early weeks of treatment the circumstances preceding the grand mal at-
tacks were impossible to learn. But after her reactions were better understood,
one could predict with fair certaintly the kind of external events to which
her reactions were inadequate and which would probably result in a grand
mal attack.
I have described generally her extreme intolerance of physical hurt and
128 THE TRAUMATIC NEUROSES OF WAR
general chaotic response to all sensory stimuli stronger than customary. ‘This
characteristic had many elaborations and could readily be identified in cer-
tain transference reactions. While she was attending school, the authorities
submitted all children to the Schick test which, as we know, involves being
pricked by a needle. She carried on violently while it was done and returned
from school quite ill.
She had several severe spells following this. From her reactions it could
readily be seen that she could react the same way to an injury to another
person narcissistically identified with herself. Although the patient had had
no grand mal attack in three weeks, it was safe to predict an attack on this
occasion.
She was told by one of her playmates that one of her friends, a boy of
fourteen, had been run over by an automobile. She became obsessed with the
description of how it happened, could not sleep at night, and saw me the next
day in quite a disturbed frame of mind. She could only say that she pictured
the injured boy in bed and felt the shock to his mother and that upon hearing
the news she became nauseated, saw double, grew dizzy, but did not faint.
No urging could get more out of her. She did not cry or look sad or depressed.
She had a grand mal attack during the same night and a petit mal attack
while telling me her story.
A feature soon felt in her mental life was the peculiar character of her
fantasy life. Not very rich or elaborate, her interests and fantasies were rather
stereotyped. Of the moving pictures she saw, she remembered chiefly fighting,
accidents, collisions, battles, and the like, although she often referred in a
perfunctory manner to the hero or heroine. She still read fairy tales persistently,
and though she spoke of the prince and princess and the happy ending, she was
a great deal more interested in the snakes, dragons, witches, spooks, pygmies,
and funny faces. In fact, fantasying about “funny faces” was one of her
favorite pastimes. During her sleepless rests in bed she would evoke these fan-
tasies of horror, unaccompanied by fear of anxiety, until she fell asleep. “I can’t
sleep until after I see them, and then I turn over and dream about them.”
These fantasy activities were of the same nature as the repetitive dreams of
the traumatic. They followed the pattern of actively repeating a trauma first
passively experienced, a reaction characteristic of the infantile method of over-
coming traumatic experiences.
Another favorite activity was to press her eyeballs with her fingers for a
while, then look up to see the objects in the room blurred or double. She often
did this before she went to sleep. She did it once in my presence, while I was
talking to her mother. She interrupted the conversation to tell me of her sen-
sations, her face pallid, with an expression of mingled fear and delight. This
sensation is undoubtedly related to the petit mal attacks. It likewise belongs to
the infantile pattern of making the best of a lower plane of adaptation—to
ANALYSIS OF THE SYMPTOMATOLOGY 129
describe pure stimulus pleasure at the expense of deleting the meaning and
pleasure value of the objects seen.
After the disease had lasted about two years, the patient became more and
more subject to clouded states and finally died in status epilepticus.
The features I wish to emphasize in this case are those in common
with the traumatic neurosis. The disease received its final form in the
petit and grand mal attacks on the occasion of a fright. The patient
had dreams which repeated the trauma or variations of it. She had
an “epileptic character” before the trauma, to be sure, which became
especially marked after it. The irritability was marked, as was also
the chaotic response to painful stimuli. She showed a complete inca-
pacity to have done with the trauma. She possessed marked hyper-
motility and destructiveness since earliest childhood, extreme aggres-
siveness and pugnacity, and a flight into the spell when she failed to
get adequate expression for them. The regression of interest is likewise
significant.
But this patient showed a trait which must be emphasized. In many
of her activities she attempted to turn her disease symptoms to good
account by endowing them with a highly pleasurable interest. These
activities were:
1. The spontaneous and voluntary production of dazed and
blurred vision, in imitation of her vertigo; her pleasure was obvious.
2. Ihe use of purposeless movements of the hands and legs for
pleasurable purposes.
3. The indulgence in masochistic fantasies and the emphasis on
the ugly, hideous, and harmful.
The relation of the trauma to the patient’s disease and dream life
showed a striking resemblance to that described for the traumatic neu-
rosis. Her reaction to the trauma, however, was an exaggeration of a
reaction previously characterizing her adaptation. As her history
shows, her adaptation had been, as it were, a series of responses to
little traumata. The recurrent dreams show her to be more fixated on
one trauma—the fright of the dog—than on any other. Dreams of
this type occur in early epilepsies without any known precipitating
trauma; in fact annihilation dreams (or aggression dreams, the two
being identical psychologically) are not specific to epilepsy or trau-
130 THE TRAUMATIC NEUROSES OF WAR
matic neurosis. I have cited a case of fractured skull and a case of
arteriosclerosis in which these dreams occurred.
The following case illustrates the dreams of an epileptic whose
illness was of three weeks duration when first seen and in whom
annihilation dreams preceded the first seizure by several months.
The patient was twenty-one years old, a nurse, the fourth of seven children.
Her family history was negative. Her childhood was uneventful; she had had
the usual diseases with no untoward effects. She had had no difficulty at wean-
ing or in controlling her sphincters in childhood. She had been a mischievous,
headstrong, obstinate child, always disagreeable and always insistent on having
her own way. She bore disappointments poorly. She had no infantile phobias
and was not especially timid. As she grew up, she became rather high-tempered,
easily excited, readily angered, and prone to motor expression of anger. She
was rather envious in nature and not religious. She remembers no fright or
trauma in childhood. She stood physical illness well. She was particularly
worried about family and economic affairs. In reference to her sex life, she
denied masturbation, fantasies, or sex experiences of any kind. She was not
attracted to the opposite sex but maintained friendly relations with a young
man during the few years previous.
Her first symptoms began at nineteen with spells of vertigo coming on at
various times, apparently with no relation to external events. Her menstrual
periods became especially difficult to her. She had severe unilateral migraine
headaches and shooting pains in her head, both lasting fifteen to twenty
minutes. Her stomach was “out of order” for some time preceding her spells.
She had attacks of palpitation without anxiety. She had felt generally “stiffer”
for some time and had hallucinatory paresthesias, especially tingling of the
tongue and heaviness of the lower jaw.
For the two months before I saw her, she had felt vaguely unwell, with
a sense that things were unusually difficult for her, although she noticed no
change in any particular aspect of her life. She knew of no external or in-
ternal conflicts.
Sleep had become more difficult in the months prior to her visit to me; it
was especially difficult to fall asleep. She had always been a prolific dreamer
but could not remember her dreams. For several months she had been having
nightmares dealing with annihilation. “I was out with a friend swimming.
I began to drown. I cried for help and awoke frightened.” The content of
other dreams was of robberies, murders, and of those closest to her being
killed. Her brother, to whom she was much attached, was constantly being
killed in her dreams. Some time before the first spell she dreamed that she
was tied to a stake and being beaten. From these dreams she would awaken
crying and could not fall asleep again; then she would dream the same dream
ANALYSIS OF THE SYMPTOMATOLOGY 147
over again or would begin dreaming where she left off. Three weeks prior
to her visit, while in a theatre with a friend, she “didn’t feel right.”’ She began
to shake and felt dizzy. She walked out, stood in the lobby for a few minutes,
then fell into a heap. Short tonic and clonic stages followed. She had seven at-
tacks since, none preceded by an aura besides vertigo, with an abrupt loss of
consciousness lasting fifteen to twenty minutes. She comes out of a spell dis-
oriented and dazed. Objects near her “move about,” things appear double,
“the place does not look the same,” “I don’t recognize myself or the place I’m
in.” On one occasion she had three spells within as many hours. A deep sleep
of several hours duration follows a spell.
Her disturbing dreams continued: “I went to the beach and went out too
far. I cried for help, but I couldn’t get any. I awoke frightened.” Her pares-
thesias have continued especially in the right hand. Parts of her body felt
“numb and dead.” Very easily fatigued, she tended to become stiff all over if
she sat quietly. She was restless, easily frightened by noise, and apprehensive
when she saw a person or an animal hurt or injured. Her vertigo was vestibu-
lar and kinesthetic: “I don’t feel my body. I feel as if I were walking on
clouds or left hanging in the air.” She described a queer spasm of the mouth.
No petit mal attacks and no break in thought continuity occurred. She became
more irritable and cranky, intolerant of noise, and was awakened by the
slightest stir in the house. The periodicity of her attacks was quite obvious.
All attacks or groups of attacks came exactly a week apart. ‘There were no
displacements in phobias. Her anxiety related to her illness, for she believed
the prognosis of epilepsy to be bad.
In contrast to this case let me refer to the conversion hysteria of a patient
who had recurrent fainting attacks based on a father identification. Her
father had suddenly died of cardiac disease ten years before. A marked mother
attachment displaced onto her sister was the motive for the identification with
her father. She had no convulsion but lost consciousness abruptly with a
constant aura of shooting pain about the heart. She had a hypochondriacal
phobia of heart disease. She had no disturbing dreams, no irritability, no out-
bursts of temper, no autonomic disturbances or paresthesias, and no sensitive-
ness to noise. She would awaken from her spell tired but not dazed or dis-
oriented, and she did not sleep after it. The faint represented a definite sexual
urge and object attachment with no resemblance to epilepsy in any way.
CoNCLUSION
The material given up to this point permits us to state our problem
more concretely. Such a statement will help us formulate the direction
in which we must look for a theoretical reconstruction.
The reactions to traumatic experience have shown us that 1n a cer-
132 THE TRAUMATIC NEUROSES OF WAR
tain number of well-defined clinical pictures the damage is inflicted
upon certain basic ego functions which, as a result of the trauma, be-
come protectively inhibited. This protective inhibition is as character-
istic of somatic portions of the ego (fractured limb) as of ideational
processes (repression) which are utilized by the ego. The traumatic
neuroses demonstrate the elementary forms of these contractile proc-
esses, together with the disturbances created in “instinct” discharge
and the efforts at restitution. In the traumatic neurosis this injury
is still fresh, that is, no time has lapsed in which its effects can influ-
ence the remaining aspects of the ego; the trauma strikes an already
completed organism.
The principle of the traumatic neurosis can be traced from minor
traumata to the more severe, as in the case of a fractured skull. The
repetitive dreams, irritability, and so on, are always present. The
resulting inhibition may be localized and involve a circumscribed
action (for instance, horseback riding) or may be more general and
include the functions of the ego involved in the more highly inte-
grated sensory-motor-integrative formulas. The contractions may
involve not only specific action integrations but entire functional units
(sensory or motor organs) and, in the epileptiform reactions, the en-
tire sensorium. These inhibitions have certain secondary effects; the
autonomic system may remain the avenue of discharge—or in the
epileptic reaction, the voluntary muscular system—without, however,
being regulated or modified by the sensorium. Secondly, the tensions
thus inhibited are discharged in disorganized aggression in the in-
tervals between the seizures.
From the point of view of dynamics the epileptic reaction is not so
isolated. In epilepsy we have the most extreme of these contractile
reactions, which we may consider a process very like repression. But
the interference with function in epilepsy has two distinctive charac-
teristics: a) It is probably organic in nature, and b) it is much older
than in traumatic neurosis and has had an opportunity to influence the
development of the entire personality. Moreover, in epilepsy the
aggression has been subject to secondary efforts at binding, either
through the influence of the “superego” (guilt-masochism) or “sub-
limation” (Dostojevsky).
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
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PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
IV. THE DEVELOPMENT OF THE EFFECTIVE EGO
INTRODUCTION: METHODOLOGY
THE MATERIAL presented up to this point can hardly be considered
complete even as far as the phenomenology of the traumatic neurosis
is concerned, for the more delicate our criteria the more detailed our
observations would be. But even though incomplete, we have enough
data for a theoretical reconstruction of the dynamics of this syndrome.
Some essentials of the probable dynamics we have already indicated
but so far have not presented a consistent theory.
A good theory must satisfy several requirements: It must be con-
sistent with the data; the data and the theory must be mutually trans-
latable into each other, for if they fail to do so all we can expect
is not a workable theory but an explanation which cannot be a guide
for action. The theory for this particular traumatic syndrome must,
moreover, be consistent with the theory of the neuroses generally,
for it is inconceivable that special adaptations are devised for this
neurosis, based on principles that cannot be identified in any other
syndrome. This last condition—the consonance of the theory with a
general theory of the neuroses—promises a good deal of trouble.
A theory in psychopathology is generally constructed as follows.
There is: 1) the direct experience of the subject; 2) his behavior;
3) constructs, which are abbreviated symbols for complicated entities
which occur very often, such as the concepts conflict or unconscious ;
then there are 4) operational concepts and finally 5) the explanations.
The operational concept is an organizing tool; it supplies a focus for
arranging the phenomena. Such a concept is “instinct.” And the
explanation attempts to establish the relations into which the recorded
events enter. This can be done in symbolic, analogical, pictorial,
dramatic, or dynamic manner. Only the latter type of explanation is
of use for therapy and research, and is naturally the type toward
which we aim.
136 THE TRAUMATIC NEUROSES OF WAR
Little difficulty is likely to be encountered in either the direct
experience or the behavior of the subject. Constructs, to be useful,
must be defined carefully. Most of our difficulties are likely to be
encountered in connection with the operational concepts and the
explanations contingent upon them.
In connection with operational concepts we are obliged to make
a crucial decision. Since we have been operating with psychoanalytic
constructs, we run into great difficulty if we attempt to use the cardinal
psychoanalytic operational concept of instinct (or Trieb—drive).
Freud explored the vicissitudes of the sexual “instinct” during the
development and growth of the individual with great precision. He
was able to do this because the modalities of the sexual instinct could
be identified through qualities derived from parts of the body (ero-
genous zones). He operated with the assumption that “instinct” in-
volves the cause of an activity, the goal of the activity, and the specific
manipulations necessary to carry out the activity. The sexual “in-
stinct”” moreover had a definite somatic reference, although there was,
and still is, considerable confusion about the somatic source of the “in-
stinct” and its executive. Time has proved that some of the phenom-
ena which Freud considered attributes of “‘instinct” now must be
considered attributes of the personality as a whole. Moreover he rec-
ognized that there were instincts other than sexual, generally grouped
under the name of “ego instincts,”” whose attributes were not defined,
whose ontogenesis could not be traced, and whose vicissitudes could
not be followed. In other words, the criteria he worked out for the
sexual instincts failed in their application to the “ego instincts” and
the nominal recognition of this latter group could be put to no effec-
tual clinical use. This failure was a signal to Freud that something
was wrong with the use of “instinct”? as an operational tool; but its
triumphs in the past made it too valuable to discard, and instead he
substituted a certain philosophical reconciliation of the discrepancy by
calling the sexual and as yet undefined ego instincts “Eros,” or life
instincts, in contrast to the death instinct, which attempted to reinstate
the inorganic state. Whatever the merits of his latter theory, its
clinical application is extremely limited save for “explanations” that
owe no responsibility to clinical procedure. It is not an instrument for
THE DEVELOPMENT OF THE EFFECTIVE EGO 137
unearthing new facts or establishing new relationships, because it does
not analyze the specific activities necessary to carry out the drive. In
the case of the sexual drive, its vicissitudes could be followed with
sufficient accuracy with the qualitative criteria furnished by the libido
theory. Eros and death instinct are still further removed from the
clinical facts.
As a consequence of this failure, the traumatic neuroses fared badly
in psychoanalysis, Overshadowed in importance—save in time of
war—by the ubiquitous transference neuroses, its nosological position
was unsettled, being considered variously a narcissistic neurosis, an
actual neurosis, or a hysteriform condition. The psychopathology was
considered, notwithstanding nosological concessions, a special case of
what happens in all other neuroses. Therapeutic procedure was a
hangover of the abreactive measures usually induced by hypnosis, to
which the theory had little, if any, relevancy. The early efforts of
Abraham (28), Simmel (28, 86), Ferenczi (28), and Jones (28),
were inconclusive, and Freud himself struck a new note on the whole
subject in 1921 (36), by calling attention to the fact that the essential
characteristic of the catastrophic dream of the traumatic neurosis 1s
that the normal defense against stimuli (Reizschutz) had been broken
through, and that the neurosis consisted of the consequences of this
rupture, and the subsequent efforts at mastering the vast quantity
of stimuli that overwhelm the subject. This was by far the most
valuable idea ever advanced about the nature of the traumatic neu-
rosis. It did not, however, solve the problem; for Freud gave no in-
dication of how this defense against stimuli was built up, what were its
manifestations in the fully developed organism, and furthermore how
this conception could be reconciled with the theory of instincts. It is
this gap which this book purports to fill.
The distinguishing feature of Freud’s instinct theory is that it
is based on a conative—which denotes appetitive striving—and not a
structural principle like sensation or reflex. But like the classical psy-
chologies and behaviorism, psychoanalysis is an atomistic psychology
which attempts to derive complex entities from the action of a syn-
thetic principle (association, conditioning, integration) on or about
a basic unit. This made particular difficulties because the basic unit
138 THE TRAUMATIC NEUROSES OF WAR
(instinct) could not be observed directly, but had to be deduced from
those compounds that made up the bulk of the direct experience of
the subject. Hence the conative and qualitative elements were stressed
and the structural elements underplayed, if not ignored, because
except for conversion hysteria and depersonalization phenomena, this
aspect of the personality as a whole, the actual executive apparatus,
was not conspicuously involved in the pathology. That is, it was
only the uses to which this apparatus was to be directed which came
into question, but not the apparatus itself. The difference between
the two can be illustrated as follows: In the first case a man cannot
strike his neighbor because there is a law or convention against it (so-
cial control); in the second, he cannot strike the blow because the
apparatus for action has been impaired somewhere in its complex
organization. Hence the diagnosis of qualities was a sufficiently ac-
curate guide in the case of the sexual instinct, but hardly in the case
of the “ego instincts.”
In the case of the sexual “instinct” then this procedure was quite
successful, and were it not for the fact that there was no psychopathol-
ogy of the “ego instincts” (self preservation, hunger satisfying
activity, aggression, or any organized activity) the operational effec-
tiveness of the instinct theory for all types of clinical phenomena
would hardly have been questioned. If we attempt to apply the
instinct theory to the traumatic neuroses we immediately run into
difficulty if we try to operate with the “instinct” of self preservation,
which is apparently the instinct involved in this neurosis. Here the
conative element, though easily conceded by common sense, is very
elusive; the pleasure element is not confined to specific erogenous
zones; there is no pursuit of an orgastic objective, the somatic refer-
ence as to source is extremely diffuse, though executive systems could
be located; they had predominantly a utility and not a pleasure func-
tion. So that the description of the so-called instinct reduces itself to
a description of specific activities, and the organs or systems through
which they are executed, from reflexes to those of the most highly
integrated intellectual character. We cannot use the concept “instinct”
in describing these complex activities with the same hope of success
as we did in the case of the sexual drive and whether it creates in-
THE DEVELOPMENT OF THE EFFECTIVE EGO ‘139
compatibilities with the instinct theory or not, we are obliged to use
another technique. Since most activities are obviously learned and
integrated slowly during growth and development, it is more difficult
to isolate the instinctive quality. This failure of the concept “instinct”
is an instance of how an operational concept and the primary data are
not translatable one into the other, and illustrates one of the penalties
for using a conative principle as an atomic unit to reconstruct the
molecules of experience. It was bound to fail in the traumatic neurosis
no matter how wide a connotation one gave the concept “sexual.” In
the case of the traumatic neurosis, unlike the others, the facade is
made up of modalities of activity, and a conative principle is not suited
to the analysis of these modalities, the essential manifest properties
of which are morphological and not conative or qualitative. We lack
the guides of erogenous zone qualities, and those attempts to explain
this neurosis with the aid of the theory of instincts only succeeded in
isolating the so-called stage of development at which a probable arrest
took place. Such an analysis leaves the essential phenomena of the
traumatic neurosis unaccounted for.
Fenichel (23) has made an excellent summary of the generally ac-
cepted psychoanalytic views on this neurosis. But we must here note
that a trauma is defined as 1) anything that stimulates the infantile
sexual impulses and 2) anything that increases anxiety which relates
to infantile experience, 7.e., factors which accentuate bad conscience,
which emphasize the reality of castration, as loss of parental love or
the protection of destiny. This definition of trauma is one that we
cannot accept, because it assumes that the only place where the individ-
ual can suffer frustrations in his ontogenetic development lies in the
pursuit of organ-pleasure, but that those aspects of adaptation which
have to do with successful accommodation to the outer physical world
are subject to no developmental vicissitudes or failures, and that gaps,
inhibitions, compensations cannot exist in these more elementary as-
pects of adaptation and the organ systems by which it is effected. Or at
best they must inevitably be related to the particular pleasure zone
dominant at each particular phase of development. It also assumes
that the social control of impulse, first by the parent and later by its
internalized representative—the super-ego—are only factors which
140 THE TRAUMATIC NEUROSES OF WAR
determine the distortions of development. As a result of this assump-
tion—one which cannot be maintained by any who have had actual
contact with them—the traumatic neuroses had to fit into the mould
of the other neuroses. The primary force in creating this neurosis, like
all others, had to be the necessity of the individual to submit to the
social control of impulses; the rédle of actual failure of executive re-
sources in the adaptation to the outer world has no place in this theory.
Even if we accept this theory, it does not account for the phenomena
of the traumatic neuroses. There is fortunately another alternative.
We can solve the problem not by compelling the traumatic neuroses
to fit the mould of the other neuroses, but by using operational con-
cepts that fit the phenomena of all neuroses equally well. This pro-
gram necessitates some alteration in our operational concepts, and
hence gives a new direction to our explanations. Since a conative prin-
ciple (“instinct”) fails us in evaluating the phenomena of the trau-
matic neurosis we can essay a structural principle, and allow the
conative element to exist in the form of an implication that whatever
structural elements we examine are in themselves already manifesta-
tions of the implicit drive. This is another way of saying that our op-
erational concept is drive plus action syndrome. But since the drive is
implicit no matter what the action syndrome is, it is only the latter
which furnishes us reliable differential criteria. It is much less of a risk
to use the morphological principle and leave the drive implicit, than
vice versa. Nor need we be too squeamish about the use of large
molecular units—action syndromes—which are complex in their
composition, if they are serviceable, rather than atomic units (instinct)
which are useless because they cannot be identified in the clinical data,
or because they furnish too few differential criteria.
Instead of the “instinct”? as an operational unit, we can use the
action syndrome. Instead of the criteria of the erogenous zones, we can
study how activity to the outer world is integrated, and study the
vicissitudes to which this development is subject, particularly those
attendant upon failures.
For the time being we can defer the issue of how this fits in with
the general theory of the neuroses (see pp. 177-205).
THE DEVELOPMENT OF THE EFFECTIVE EGO 141
Wuat 1s ADAPTATION?
In order to discuss the dynamics of the traumatic neurosis we must
first have a working definition of adaptation pertinent to those vicissi-
tudes we have observed. Adaptation is a series of maneuvers in re-
sponse to changes in the external environment, or to changes within
the organism, which compel some activity in the outer world to the
end of continuing existence, to remaining intact or free from harm, and
to matntain controlled contact with it. The changes that take place
within the organism, such as anabolic and catabolic processes or those
that govern the relations between the various organ systems, can
hardly be considered adaptation; but they have a decided bearing on
the adaptive activities of the organism to the outer world. The need
for nutriment, the perception of which can be designated as a need-
tension, determines a group of activities in the outer world specific to
each organism.
The activities of the organism are qualified by the nature of the
contacts it is phylogenetically equipped to make with the world by
means of receptor and effector apparatus. Receptor apparatus serves
the end of orientation and perception of qualities and the effector
apparatus to subject the outer world to its own ends. Another portion
of the adaptive apparatus has a codrdinative function. It is through
the codperation of these three systems that the outer world acquires a
meaning to the organism. The meaning of the outer world varies,
depending upon the degree of refinement of the contacts the organism
is able to establish, the dexterity of its effector apparatus and the
effectiveness of its codrdinative functions. When the outer world
becomes meaningful in connection with sensory, interpretive and
manipulative functions, this meaning takes on a characteristic which
may be designated as w#ility. The organs or systems through which
this utility is realized may be said—among others—to have a utility
function. No part of the organism is devoid of this function, but they
vary in degree. In man the eye, hand, lower extremities and ears have
the highest utility function. The effective exploitation of the meaning
of the outer world through the utility function of organs can be
142 |. THE TRAUMATIC NEUROSES OF WAR
designated as mastery, a construct which means a controlled exploita-
tion of objects in the outer world.
Adaptation to the outer world—exclusive of the social environ-
ment where the process is much more complicated—can be generally
classified in certain gross modalities. 1) Active mastery is one in
which the utility of an object can be fully exploited, e.g., eating or
making a tool; or circumventing the interference of another object,
successful combat. 2) Passive mastery, such as flight, escape, or avoid-
ance through immobilization, of a noxious object. Both these types
can be effective and the organism remain intact. 3) But the organism
can also be overwhelmed and destroyed. 4) The organism can remain
intact, life continuing, but the adaptive maneuvers are altered. This
latter modality of adaption corresponds to neither of the other three
and is the form we encountered in the traumatic neurosis. In order to
understand this type of adaptation we must examine how the receptor,
coérdinative, and effector systems are integrated into effective action
syndromes. This is a genetic problem. Then we can study the relation
of these data to those found in the traumatic neurosis.
DEVELOPMENT OF ADAPTIVE PATTERNS
It is an obvious fact that man’s adaptive patterns are in a constant
state of change from birth on, although some of them become stabil-
ized in childhood. The reason for this constant change is that his
resources change through growth. He is born helpless, and although
the phylogenetically predetermined organic substratum is present, the
actual techniques and manipulations must be learned and gradually
integrated into effective tools. The concept “instinct” does not cover
that learned processes although we can safely predicate a drive. The
development of these adaptive processes must be studied genetically
in order to understand the various places at which failures or arrests
may occur. We must study the conditions under which these action
syndromes—our unit of study—can and cannot be formed, the condi-
tions that maintain them or permit them to disintegrate, and the
consequences of these various vicissitudes on the personality as a
whole.
THE DEVELOPMENT OF THE EFFECTIVE EGO 143
At birth only the automatic functions—anabolic and catabolic—are
effective, with the aid of a few reflexes, the chief of which is sucking.
The infant’s adaptation is passive as far as the outer world is concerned ;
it has no controlled contact with the outer world except insofar as this
is mediated through the mother. It cannot choose, avoid or seek out
objects in the outer world necessary for its survival. Even heat reg-
ulating apparatus and certain metabolic processes are not stabilized
(Cannon).
Being born may be said to have already interfered with the equi-
librium of the intrauterine state, because stimuli are now registered on
the organism from within (hunger) and without (cold). To relieve
these need tensions the infant must lean periodically to the outer
world, or show signs of the unpleasant effect created by them. To
food brought to it the child can respond by sucking, for which the
nerve paths have already been myelinated.
The whole process of myelination in man is very slow, (51) not
being completed until the third year. This fact is signal for human de-
velopment, though it may not alone be responsible for its specific
course. [he motor nerves myelinate first, the sensory later. This
anatomical fact has a special significance; it increases the adaptation
possibilities enormously; it means that action is learned in contact
with the environment and is not phylogenetically predetermined.
Creatures whose myeliation is completed shortly after birth have
fewer adaptation possibilities. This fact, however, introduces an ele-
ment of chance in development and introduces more places where
failures can occur. On the other hand it guarantees a closer tie between
environmental conditions and the action syndromes necessary for sur-
vival. It makes the period of dependency longer, but it guarantees
greater plasticity and augments the adaptation possibilities. Generally
the functional capacities run parallel to the degree of myelination—
at least for a time [ Monakow (65) ]. In premature births myelination
takes place in a shorter time. If light is admitted into one eye of a
mammal and excluded from the other, the fibres of the former myeli-
nate more rapidly than the other. This phenomenon means that
motor development is effected with a psychic and personal counter-
144 THE TRAUMATIC NEUROSES OF WAR
part; it also means that this aspect of development is vulnerable to
insults.
The newborn already has reflex mechanisms (9) 1) for excluding
stimuli: closing the eyes on a strong light; 2) for continuing a re-
sponse, like deep breathing when smell is stimulated; 3) an un-
coérdinated “discharge” on sudden noise, which is either the Moro
reflex or the “startle pattern” [| Landis (54) ], and finally crying and
kicking.
The first zone at which any organized reaction takes place is at the
mouth. Sucking is reflex—though it may take some time to establish.
But at this very first zone we must note that the reflex activity is not
independent of success or failure. If the child fails to grasp the nipple
after two or three attempts, it becomes stuporous, and after several
failures the reflex sensitivity of the mouth disappears [Ribble (78) ].
The sleep under these conditions differs from the satisfied sleep after
feeding. Breathing is irregular and the skin pale. The successful feed-
ing reduces the hunger tension and to it is added a new quality, satis-
faction, and at the mouth perhaps a specific pleasure quality. If the
whole process succeeds there is an eagerness to renew the activity when
the tension arises again, a recognition of the satisfying object (mother
—breast—bottle) and an effective attachment to it. The events after
success and failure are quite different, and are quite like the results
reported by reflexologists. The failure is followed by an inhibitory
process, one of the immediate consequences of which may be profound
shock. A similar mechanism of inhibitory processes may be at the basis
of marasmus.
The integrative processes at the receptors eye and ear are somewhat
more complicated, and their steps can only be approximated. Follow-
ing an object, the development of accommodation, then the ability to
seek out objects, eidetic vision, are recognizable stages of seeing. The
most important steps in connection with vision are appreciation of
form and spatial relations, especially perspective. The latter function
cannot be really effective until motility of the limbs is considerably
advanced.
The sense of hearing has an important réle to play in orientation.
The first responses to loud noise are those of fright; but this response
THE DEVELOPMENT OF THE EFFECTIVE EGO 145
tends to diminish in the first three months. The first reaction to
succeed fright is that of fixed attention followed by expressions of
pleasure. Then comes the ability to turn the head in the direction of
noise and finally to seek the source with its eyes and fixate on it. This
allays the disturbing effect of the noise. Rhythmic, repeated sounds
elicit gratification, and moderate sounds which first occasion fright
are subsequently enjoyed.
The chief characteristic of the adaptations of this period is that
they are effected without codrdinated motor activity, and consist of
the organization of pleasant sensory stimuli at oral, visual and acoustic
zones and a response in the form of laughter. Reactions to unpleasant
tensions coming from within and without consist of discharge phenom-
ena—tfright reactions, crying, kicking.
In between these two types of response is the attitude of fixed
attention. A stimulus first repudiated by defensive activities can by
attention, repetition and memory traces of pleasure be recognized and
then sought after and enjoyed. Laughter and the desire for repetition
of the stimulus follow. Both repetition and laughter represent a stage
of mastery.
The reaction of fright is quite different, and the only important
thing about it is that if this reaction persists to the same stimulus, no
organization for continuing the stimulus can be effected. The stimulus
which first causes fright may later be enjoyed. This is another way of
stating that some form of pain initiates inhibitions. In the fright re-
actions of infants the likelihood is that the sensory element in the
painful experience retreats, the sense organ is protected, and the re-
action terminates in a painful discharge. It is highly probable, there-
fore, that in infancy only pleasant affective repetitions lead to per-
ception and to reproductory processes which aim to recall the pleasant
experience. This does not mean that later painful experiences in
activities which are unavoidable are not integrated. They are, in a
highly characteristic manner (see pp. 123-129).
No definite evidence exists concerning the time when the infant is
able to experience anxiety. It is difficult to identify the infant’s reaction
to tensions like hunger and frustrations as anxiety. Anxiety 1s primar-
ily a reaction to a perceived or anticipated danger situation. Reactions
146 THE TRAUMATIC NEUROSES OF WAR
to painful situations are not necessarily anxiety. A stimulus may first
cause fright, and later anxiety, if the fright-provoking agent can be
identified. The same frightening stimulus may on repetition prove
agreeable. Anxiety can occur only when the painful or threatening
stimulus can be identified or anticipated. Strange or unfamiliar stimuli
may provoke anxiety. Fright remains throughout life a disorganized
response to sudden stimuli; anxiety can lead to highly organized
defensive measures. To fright no organized defense is possible.
Whereas the infant cannot choose stimuli, it can utilize only those
that are pleasant. In this respect it enjoys an advantage over the adult;
it can flee painful stimuli without impairing its integrity. Fright reac-
tions can take place at any time in life. By virtue of the fact that it is an
ectoparasite, most of the infant’s needs can be taken care of by the
parent. This resiliency is lost by the adult, so that a traumatic experi-
ence striking an adult has a much thicker layer of protective devices
to break through; but once having done so, the ego cannot dispose
of it so readily as can the infant.
THE DEVELOPMENT OF MasTERY—AUTOMATIZATION OF
Functions (9)
We have noted that active mastery is one of the techniques of adap-
tation. Active mastery means the capacity to exploit the utility (or
pleasure) value of objects in the outer world for one’s own ends. In
the development of this technique motility and manipulation play a
decisive rdle. Both of these add much to adaptation possibilities, but
they also increase the complicity of the outer world; they alter the
meaning of objects in the outer world, their utility and pleasure possi-
bilities. They also increase the opportunities for experimentation,
choice, and failure.
It is on the motility and manipulative systems that the slowness of
myelination has the greatest effect. Reflex grasping does not yet be-
long in the group of codrdinated activities. Motility and manipulation
add a new factor to the optical, acoustic, and oral experiences, namely
kinesthetic.
The first types of motion that we can call purposeful are fusions
THE DEVELOPMENT OF THE EFFECTIVE EGO 147
of certain elements of which we can identify three: 1) optical, 2)
kinesthetic, and 3) memory of success or gratification. When these
three unite in the interest of purpose, mastery begins.
When the infant learns to grasp after an object that already gave
it pleasure, we now have a habitual mode of response, one portion of
which is purely psychic—the memory of gratification and the urge
for more gratification—and the other, written into a motion melody
of following the object with the eye and grasping for it. The latter
component becomes automatized, and in the organism as a whole a
manipulative activity takes place which tends to restore the absence of
tension. The reflexologists have established how such automatizations
take place, the vicissitudes to which they are subject and the conditions
that modify them. In comparison with what takes place in the infant
in the automatization of pleasure-yielding action syntheses, there is no
difference in principle.
Schilder (83-85) has pointed out that the building of these action
syntheses is not always simple. It may happen that in carrying out cer-
tain motions, the pleasure value of individual components may out-
weigh others, with the result of enhancing the pleasure value of the
completed action. Thus, when a child grasps an object with the hand,
the optical portion of the experience may absorb much of the pleasure
value of the hand motion. At one phase of development of this com-
leted action, which starts as “instinctive” grasping, the optical value
of the total experience may draw the greatest amount of interest. This
fact is very important for the establishment of the sense of spatial
orientation for various parts of the body in relation to each other and
to the external world. The optical value of the arm is probably greater
than any other portion of the body; the lower extremities have much
less optical value, due possibly to the relatively late development of
walking; the head has very little; and those mobile parts of the body
that cannot be seen have no optical pleasure value at all.
In the infant the technique of mastery has two chief executive
organs, the hand and the mouth, the eye being the leading auxiliary
organ. The sense of vision determines chiefly what objects in the outer
world will engage the child. Thus sounds do not elicit active response
unless the source is seen; nor do tactile stimuli, though these latter
148 THE TRAUMATIC NEUROSES OF WAR
are not quite so dependent upon sight as are auditory stimuli [ Bern-
feld (9)]. In the fourth month of life the mastery technique consists
of seeing an object, grasping it and directing it to the mouth. This
may be called the phase of oral mastery.
One important fact must be noted in connection with oral mastery;
objects placed in the mouth are not swallowed. Oral mastery is most
prominent when sucking and swallowing are responses only to liquids
of a definite quality. At the time when solid food is chewed and
swallowed, the result of oral mastery is not devouring but pleasure
sucking, nibbling, and holding the object for a short time at or near
the mouth. Bernfeld believes that tasting plays a relatively insignifi-
cant part in this process. Neither can the relationship between eating
and oral mastery be definitely established. After weaning some
children have a tendency to devour everything—pennies, pins, and
so on—but the meaning of this is still problematical.
The stage of oral mastery is important because it includes the be-
ginnings of a process whereby the sense organs and erogenous zones
have brought groups of perceptions and feelings into codrdination
under the domination of a central apparatus. At this stage the grasping
of an object involves psychic processes involving the arm, hand, opti-
cal zone, and oral zone. The oral zone is the objective; the optical
zone has a demonstrative function; and the motor zone, an auxiliary
function. This is the first evidence of an integrated, meaningful action
syndrome and it begins to function when the effect of visual experi-
ence, perceptions and the expectation of pleasure have become suf-
ficiently large to release or inhibit specific motor effects [Bernfeld
(9)]. In relation to certain perceptions and ideas a concentration of
psychic energy has occurred, placing the motor apparatus in the serv-
ice of the ego—the codrdinator of action syndromes—now unified by
a common integration of its component parts. The first form of wish
fulfillment is direct and hallucinatory, the concept “I want” at this
stage having no instrument other than reproduction. When other psy-
chic processes are added at the stage of oral mastery the hallucinatory
type of repetition begins to recede, and a bit of activity takes its place.
The next development is the use of the hand in the service of zones
other than oral, and the use of the eye to seek objects for oral and
THE DEVELOPMENT OF THE EFFECTIVE EGO 149
auditory gratification. Those objects not suitable for oral mastery are
used for making noise, tearing, crushing, kneading, scratching and
plucking. In primates these activities have a definite relation to oral
activities, the object being to find out what things are edible. For this
reason it is erroneous to call such activities destructive. They are more
likely primitive, crude forms of mastery, when the meaning and
utility of the object is limited.
The oral zone is the executive for tensions arising from within—
hunger—and from without, external objects. As regards the nutri-
tional drives, part of the objective is to re-establish a state of equili-
brium in the internal environment, and part to continue stimulus
pleasure at the oral zone. The disturbance in the internal environment
which results in sensations of hunger gives rise to discomfort or pain,
motor unrest, and then perceptions concerned with the release of this
tension, first hallucinatory and then motor. The state of rest, when
disturbed by hunger, is re-established by eating; it can also be dis-
turbed, whether or not the internal environment has created the
tensions of hunger, by objects seen in the external environment which
release the wish for oral mastery. The objective of oral mastery is to
remove the disturbing object from the effective environment (the
range of vision) by rejection—partial or complete. Bernfeld dis-
tinguishes between oral mastery and oral annihilation. The distinc-
tion appears inessential.
The phase of oral mastery is important not only because it can be
identified in the ontogenesis of the ego, but because it is helpful in
the appreciation of some of the activities in the traumatic neuroses and
epilepsy. In another chapter we described a case, in which the acme
of “destructiveness” was reached in oral activities, and the patient bore
witness to this fact by demonstrating a set of teeth worn down from
chewing on articles of furniture, clothespins, and so on. Other patients
could vent their aggression only by tearing, crumpling, smashing ob-
jects about them. Still another, who was long in an unconscious state,
awakened out of it with an awareness of only one part of his body—
his mouth—and possessed of an uncontrollable desire to break, tear
and smash everything about him. About this latter case it may also be
parenthetically added that one can appreciate the world with a single
150 THE TRAUMATIC NEUROSES OF WAR
ontogenetically old type of adaptation, in this case the oral zone, all
others seemingly being blocked. This patient could not maintain
consciousness at that level, all other perceptions being either mean-
ingless or painful, and during his convalescence he continued swoon-
ing until other adaptations were re-established. This same patient re-
marked that in addition to having no awareness of any part of his body
apart from his mouth, he could not interpret the scene that struck his
eyes, no knowledge of perspective, so that all objects were “flat” and
confused. He heard people talking but did not understand words—
“They sounded like fog horns.” This inordinately strong oral adap-
tation of the traumatic neurotic is a symptom at once of his convales-
cence and regression. The return of this phase of ego development,
however, is associated in the traumatic and epileptic with the greatest
distress, unlike the infant, to whom it brings a feeling of triumph and
an enhancement of self-esteem.
One of the results of the series of integrations described is that the
child eventually gets to appreciate that it is a distinct entity apart from
other objects in the world. Ferenczi has described certain aspects of
the development of the sense of reality, and traces several basic
constellations formed in the child derived from the complicated
relationship with respect to the mother and the outer world. He
describes changes in perception, ideation, affective attitudes of the
infant coincident with changes in function and capacities of the devel-
oping organism. The outer world and body ego come to be known by
the codrdination of optical, tactile, and kinesthetic sensations in as-
sociation with motor functions under the stimulus of needs and their
gratifications. In early infancy I believe the réle of disappointing
experiences to be minimal. The rdle of pain in separating body ego
from the world has been overemphasized in the literature. To be sure,
the child learns in this way, among others, what does and does not
appertain to him. But it is only one of his means; the other is the rdle
of gratifying experiences, for only the latter are taken up for system-
atic integration. There are too many vague conditions that determine
whether a given pain has value as a delimiting factor or not. Often
one observes conditions that ought to evoke pain but really do not.
Moreover, pain is able chiefly to institute inhibitions and defenses.
THE DEVELOPMENT OF THE EFFECTIVE EGO 151
Much more important than pain is the remarkable discovery the
child makes in the connection of a movement that is carried out with
the sensory impressions received in so doing. Later a still more impor-
tant fact is added which has a very high pleasure value. The carrying
out of an action with all its sensory concomitants, optical and kines-
thetic, is associated with success, a gratifying result which gives rise to
a triumphant feeling of making an organ obedient to the will of the
ego. [The variety and number of these associations eventuate in a
definite self- or body-consciousness, which becomes the center and
point of reference of all purposeful and coérdinated activity.
One must not lose sight of the fact, however, that in this stage the
body ego represents a fusion under a central control of what were
originally a group of small entities with independent aims. In the
most primitive form there was a series of independent little egos—a
tasting-touching ego, a seeing-feeling ego, and so on. When a child
tries to grasp an object out of its reach in the oral phase of develop-
ment, it is not able to appreciate the distance between itself and the
object, and hence the grasping motion fails. At this time the body ego
has as its center the oral zone; then the eye is added to this zone as an
auxiliary; then the neck musculature, the ears, arms, back, limbs and,
last of all, the feet. The ability to use all of these combined in the
interest of grasping the object represents a relatively high organiza-
tion of the various components of the body ego. This process is capable
of infinite degrees of refinement and complicity. Perhaps the last
parts of the body that come under the government of the central ego
are the feet and toes; thus they are treated as if they were foreign
bodies for a correspondingly longer time.
Once the body ego is separated from the outer world and the
various parts of the ego subjected to central control, the rest is simply
a question of more and more complicated combinations. After sense
perception and body control are sufficiently developed to enable the
child to maintain equilibrium, two processes are of great importance
in directing future developments. To be sure, this is a rather arbitrary
way of fixing the time at which these two factors begin to operate. No
such sharp line of division can be made, although it is likely that the
establishment of equilibrium frees a large amount of energy for more
152 THE TRAUMATIC NEUROSES OF WAR
complicated forms of mastery. Whatever the time at which they
commence to function, the factors responsible for further growth of
the ego are #mitation’ and the progressive growth of intelligence,
which is really the master codrdinating apparatus.
We cannot but touch on the latter factor here. The intellect is
undoubtedly the most important weapon of mastery that man pos-
sesses, having largely the functions of selection, inhibition, and prep-
aration for action. The two specific characteristics of man as regards
his mastery drives are the phenomenal developmental capacities of
the hand and the intellect. Some authors are inclined to regard this
not as a coincidence but as indication of a common source (50). In
almost all languages there are words whose connotation is some form
of psychic appropriation and which are expressed in some form of
tactile or manual symbolism. A few of these will illustrate: the words,
grasp, wmpression, comprehend; Begriff, Vernunft (from verneh-
men), zergliedern, auslegan, tiberlegen, Eindruck; percipere, com-
prehendere, and so on.
The combination of intellect and hand has one important result as
far as man’s mastery of the world is concerned; he is able to make
infinite extensions of the hand and special senses. The objective toward
which this mastery is directed is to exploit the utility value of objects
in the outer world. This utility value may be to devour, to render
harmless, or to transform. In connection with this latter it has been
observed that this tendency is really to reinstate the period of magic
control of infancy. The combination of progressive and regressive
tendencies can best be observed in those societies where the conquest
of the external environment is most successful. Nature is subjected
and conquered, the result of this entire process being a reproduction of
the state of infantile magic, where the world obeys the will through
the mere act of pushing buttons. However, there is a difference be-
tween the two states of magic control, the infantile and the one
achieved through the subjection of nature.
One of the chief functions of the intellect in the establishment
of mastery is its inhibitory function, a fact recognized alike by neurol-
*Bernfeld (zo) uses the concept identification to convey the idea that the child does
as it sees others do. This word is better reserved for the unconscious process, rather than
the conscious process we are considering.
THE DEVELOPMENT OF THE EFFECTIVE EGO § 153
ogists, reflexologists, and psychoanalysts. Without this inhibitory
influence, no integrative purposeful actions could be established.
Important to note is that this inhibitory function is not synonymous
with repression. Purposeful action represents not only direction and
goal, but also the inhibition of a large number of adventitious phenom-
ena. In training, which represents the shutting out of useless and
superfluous action integrations, we can see not only the réle played by
the pleasure element, but that of the selective and inhibitory action of
the mind. When this inhibitory influence is removed by the extinc-
tion of consciousness, the organism is capable only of defense reactions
emanating from the lower centers. This is what occurs in the epileptic
seizure.
As regards the réle of imitation in the building of the body ego not
much is definitely known. If, for instance, the mother makes a noise
with a rattle and the child seizes it and continues the noise, this process
is not a true imitation but an active continuation of the pleasure hear-
ing. It seems to connote, “I also... and more.” The child can do this
only with such stimuli as do not provoke anxiety or fright. When we
observe a child following an object with the head and eyes, in rapt
attention, we see a phase preliminary to mastery. If mastery is inter-
fered with by the incapacities of the child, the object is nevertheless
retained by means of intensive psychic activity, to the enchancement
of first its optical value and later its auditory value. In this type of
instance Bernfeld (zo) maintains that a partial mastery is effected by
means of identification with the object. This process he calls fascina-
tion.
In the original reactions to noise we observe that the stimulus
disturbs the state of rest, resulting in an effort to flee the stimulus.
Later we find a receptive attitude to the same stimulus and an active
production of the same. Between the two is a state in which, with
anxiety and fright inhibited, there is active attention, fascination. This
latter may be associated with inhibition of activity, an anxious or even
uncanny feeling. This type of activity may eventually be followed by
active imitation, 7.e., mastery by way of identification.
The type of reaction we see in infantile fascination persists through-
out life, under conditions where mastery is impossible. One can lose
154 THE TRAUMATIC NEUROSES OF WAR
oneself in a given object or act, and thus establish a preliminary
phase of identification. In this state one is outside oneself and most
ego functions are inhibited, a condition closely related to hypnosis
and sleep. One becomes automatic in following the motions of the
object; it is a transient substitution of the ego by the object. It differs,
however, from imitation in effecting no permanent changes in the ego.
Fascination, however, may pass over into imitation, a process that
probably has much to do with the learning processes associated with
bodily posture, language, and so on.
Like fright, fascination is also dependent upon the element of un-
expectedness or surprise. I recall the first time that I heard a certain
symphonic poem in a state of fascination. Completely unaware of my
surroundings, completely immobile, I had no idea of the amount of
time that had elapsed, and automatically followed the movements
of the conductor and orchestra. There was an enormous element
of surprise and mystery. However, after I had procured a score of
the work and studied it minutely, the element of surprise was com-
pletely gone the next time I heard it, and no fascination was felt. The
same piece is now even a bit tedious to me.
Imitation and later identification play an important réle in the
development of mastery because they are processes which become in-
corporated into the ego-ideal. In relation to the instincts of mastery,
as far as the body ego is concerned, the superego has no prohibitive
or punitive function; its place is taken by the sense of reality and the
objective of self preservation or security.
There are still some data that organic neurology can supply about
the structure and functions of the body ego. We can select from this
vast amount of data only a few salient and pertinent facts. Schilder
has pointed out that certain lesions of the brain produce a diminution
of impulses (Antriebe); whereas others, a superabundance of them,
as in hyperkinesia. We know, of course, that the same conditions can
be produced by purely psychic factors.
Schilder (83, 84) is of the opinion that the subcortical impulse is
within certain limits displaceable, so that energy accustomed to dis-
charge through certain established paths may, if these channels are
anatomically blocked, be discharged through other channels. Mona-
THE DEVELOPMENT OF THE EFFECTIVE EGO 455
kow is of the same opinion. Thus a case of anatomically determined
akinesia will, under slight provocation, give vent to outbursts of
anger and violence. It would seem that energy suffering stasis in its
customary channels can only be explosively discharged in a less
organized manner. This fact is of great importance in evaluating the
explosive outbursts of the traumatic and epileptic cases. In these
latter cases the energy is psychically inhibited.
Organic neurology has a good deal of light to throw on the com-
ponent parts of voluntary motion, and certain phases in the establish-
ment of the body scheme. The facts of organic neurology indicate that
the psychic counterpart of bodily activity has a more or less inde-
pendent existence and may continue to exist long after the executive
organ ceases to function. Furthermore, the sensations associated with
a given portion of the body are intimately and inseparably tied to
the site of its functioning. It is an old observation that patients whose
extremities have been amputated continue to have the sensation that
they are still attached to the body. A man who has had his foot
amputated can continue to wiggle his toes. This is not merely a
hallucinatory gratification of the wish to retain the limb or a denial
of its loss, but a persistence of the kinesthetic sensations associated
with its functioning. Another striking observation was made during
the war when transplantations of skin from one part of the body to
another had to be made to hide certain hideous deformities. Thus
Ischlondsky (46) cites the case of a soldier whose nose, mouth and
upper jaw were completely torn away by a piece of shrapnel. To re-
construct the nose they had to graft some skin from the forearm.
Usually the skin flap on the arm is attached to its blood supply until
the flap is able to establish capillary anastomoses on the nose; then
the graft is completed and detached from the arm. If, after the new
blood supply has been completely established, the subject is made to
close his eyes and the grafted skin on the nose stuck with a pin, the
sensation is reported as being on the forearm.
Organic neurology also confirms that voluntary motion is a
synthesis of psychic and somatic components. From the phenomena
that result from interference with one or the other of these parts we
can infer that every motion has a formula [Schilder (85)]. There
156 THE TRAUMATIC NEUROSES OF WAR
must first be a visual picture of the limb or portion of the body that
carries out the motion. There is some doubt about the kinesthetic
element, some believing it present and others, not. Quite certain,
however, is that the kinesthetic element cannot replace the optical
image, though auditory and tactile stimuli can replace the visual to
a degree. Then the goal of the action must be visualized and finally,
the idea of successful completion of the act. Any completed action is,
therefore, dependent on the body as a whole and depends on a proper
evaluation as regards the completed action. This evaluation depends
on the relations of the body to the rest of the space about it, and is
therefore a spatial one. It depends on an accurate evaluation of the
body scheme; on an evaluation of the objective and the motion
formula or melody; and also on the proper innervation. The impor-
tance of this motion formula is that when we come to deal with in-
hibitions of voluntary motion, we cannot depend on the latter as
being merely an automatic unfolding of habitually recorded engrams.
Every voluntary motion is a unit; but it has a psychic portion, made
up of all the above mentioned components, aided by their meaning
and utility function. In the first few years of life these voluntary
motions become automatized. Originally the motions were probably
intrinsically pleasure giving, without meaning or use. Then voluntary
motion became subject to more and more remote objectives. The in-
terest which an activity serves is derived partly from the ultimate
goal for which it is carried out, and partly from the activity itself,
which has a certain narcissistic value. Moreover, without the idea of
successful completion of the act it would be impossible to carry out
any voluntary motion. The idea of success may be deferred, as in
learning to play the piano. Voluntary motion may, therefore, be in-
hibited when the purely psychic portions of it have been injured. This
fact is of prime importance in appreciating the inhibitions of the trau-
matic neurotic. It shows itself characteristically in the dreams where
a given action is initiated but never carried through, being interrupted
by catastrophe. The idea of successful completion has in these cases
suffered a severe blow.
This sketch of action integrations deals only with those that
terminate in some successful forms. How many difficulties are en-
THE DEVELOPMENT OF THE EFFECTIVE EGO § 157
countered in establishing them and how many types of failure there
are cannot yet be determined. No instrument of research is delicate
enough to follow them. But certain types of failure can be recognized,
which take the form of persistent destructiveness (see pp. 123-129).
This point can be used to illustrate the operational differences
between the concept destructiveness from the point of view of the
instinct theory, and from that of ego psychology. In the first case
the phenomenon must be interpreted as a regression to a stage of
development in which destructiveness was a type of effective adapta-
tion. Descriptively this cannot be called incorrect. However, the
assumption is unwarranted that the infant’s intention is destructive
or cruel. The technique of mastery is then very crude, and has noth-
ing to do with destruction as it is later understood. From the point
of view of the integration of action syndromes, the appearance of
destructiveness, whether it is called regressive or not, points in an-
other direction. It means that something has happened to the refined
forms of mastery, that they are blocked or destroyed by factors that
can be identified, The concept “regression” does not indicate where
these factors lie, nor does it furnish clues to the therapist to aid the
patient to identify and control the disturbing factors. From the point
of view of the integration of the action syndrome more differential
elements can be identified: the constant presence of anxiety can be
demonstrated; the inhibitory effect of the anxiety; the general dis-
organizing effect of the inhibition both from the point of view of
frustration of the goal of the activity, and the necessity to accommo-
date to the objects in the outer world by some other techniques. The
destructiveness is the result of all these intermediary steps, which
are not included in the concept regression.
Tue INTERNAL ENVIRONMENT AND Its ROLE IN ACTIVITY
The internal environment leads a more or less autonomous ex-
istence, being regulated by an independent nervous system, which
has, however, definite connections with the skeletal nervous system
and definite central connections. Most nerve fibres of this system have
no myelin sheath and are, therefore, capable of fewer vicissitudes after
birth than are those of the voluntary nervous system. The functions
158 THE TRAUMATIC NEUROSES OF WAR
of metabolism, digestion, respiration, circulation, secretion and en-
docrine flow are more or less complete at birth, though not stabilized,
and ordinarily little subject to the control of the will. The autonomic
nervous system is, nevertheless, keenly in touch with the outer world
through the intermediary agency of the skeletal nervous system,
sensory and perceptive apparatus.
The chief function of the autonomic system is to regulate al] in-
ternal organs so that they maintain a constant relationship to each
other and a state of equilibrium in the organism as a whole [Miller
(67) ]. It codperates with the endocrine system by means of hormonal
action. It is as wrong to assume that this internal harmony is main-
tained solely to create the preliminary conditions for an adequate re-
lation with the outer world as to assume that the reverse is true. Both
seem simultaneously true.
The functions of the autonomic nervous system and internal secre-
tory glands are related to the maintenance of an optimal balance
between the external and internal environments by regulating the
distribution of tissue fluids from the splanchnic to peripheral areas.
In this function the peripheral system not only gives the requisite
signals, but has the undoubted leadership. The autonomic system and
its associate, the endocrine, also has certain long-term functions to
perform which govern the internal harmony with relation to the gross
biological changes in the whole life trajectory of the organism. We
gather from the data of endocrinology that it has much to do with
the regulation of growth, maturation of the internal sexual apparatus,
and the functions of ovulation, menstruation, gestation, labor, involu-
tion and senescence. In connection with the “instinct” life of the in-
dividual these systems, autonomic and internal secretory, have a host
of functions whose economy and modes of operation are as yet poorly
understood. Neither do we know accurately the nature of the inter-
action of the various parts of these systems to each other or the stimuli
to which they respond. From our present state of knowledge we
cannot tell whether or not the long-term functions of these systems
are subject to influence by direct factors or unconscious emotional
processes.
The internal environment has its own defensive weapons of a
THE DEVELOPMENT OF THE EFFECTIVE EGO 159
chemical and biological nature in the blood and lymphatic systems,
which behave like liquid organs. In relation to the external environ-
ment, under the regulation of the autonomic system, the blood and
lymph have an amoeboid character; they have powers of expanding
and contracting back toward the splanchnic area.
In comparison with the relations of the infant to the external en-
vironment, its relations to the internal remain formally quite constant
throughout life. But when we consider the poverty of adaptations
that the infant has to the outer world, it is not a far-fetched in-
ference that the sensations coming from the internal environment
have a much greater significance for the infant than they have for the
adult. We have, however, no way of learning directly how these
sensations are reported to the infant or the meaning they have.
Our methods of studying this are entirely indirect. We can only
draw certain inferences about this phase of infant life from the study
of regressive phenomena, and even then we are not absolutely cer-
tain.
The inner world can only be known through such of its activities,
and the sensations that accompany them, as are capable of being
projected on the body surface. From conversion hysteria, hypo-
chondria and schizophrenia we gather that the relation of the in-
ternal environment to the emotional life is more intimate in infancy
than at any other time of life.
Much of the internal environment is, however, mute. Its func-
tions are not, except in the case of gross anatomical interference, as-
sociated with sensation, and even then can give rise only to referred
pain. This is undoubtedly true of the large glandular organs—the
liver, pancreas, spleen and kidneys. Sensations arising from these
latter organs can, however, always be referred to that great functional
unit, “the insides.”
The functions of the autonomic nervous system in dealing with
dangers arising from within and external dangers, have been ex-
haustively described in the literature. All varieties of connection have
been shown to exist between this system and the phenomena of
anxiety and fear; even the old James-Lange theory has found a place
for application, The connections between the vasovegetative system
160 THE TRAUMATIC NEUROSES OF WAR
and sexual excitement and orgastic experience have been followed
out. But least noted of all is the most elementary function of the
vasovegetative system, namely, that it alone supplies and regulates
the conditions for increased motor activity, be it for work, danger,
pleasure or flight. Freud and W. Reich (75) have long held the view
that “libido stasis” in the form of inadequate gratification can lead
to the genesis of a large amount of “free floating” anxiety. Also re-
served as a possibility must be that increased activity of the vaso-
vegetative system can be the result of blocking of the normal channels
of motor activity, this overactivity of the autonomic system not neces-
sarily being associated, in this latter case, with anxiety. It may be
associated with another quality of emotional tone, irritability.
Another view of the réle of the autonomic system (sympathetic-
parasympathetic) is held by Tarachow-Bieber.” These authors hold
that the activities of the system are not necessarily evidence of stasis
phenomena, but that they are an integral part of the action complex.
Recently important work by Alexander (3, 4) and associates,
French (29), Dunbar (17), and others, has proceeded along lines
that promise much light on the relation of the autonomic system in
activities which are under social control or the internalized representa-
tive, the superego (see p. 190). An important orientation point is the
normal and perverse autonomic accompaniments of anxiety.
Tue EFFectTIvE Eco anp FAILURE REACTIONS
Our purpose in outlining the various steps in the development of
the ego was to demonstrate its integrative character. For this purpose
we did not find the concept of “instinct” very helpful, because ir-
respective of whether or not the concept instinct is best able to convey
the idea of elementary drive, it is in no way able to convey the idea
of successive integrations welded into the actual units used by the
individual. We have indicated in a general way the dominant réle
of success and failure in the creation of these units and that the in-
herent quality of these integrations is colored by the special bias given
in favor of one or another of the components. Whatever their com-
2 . *
Personal communication.
THE DEVELOPMENT OF THE EFFECTIVE EGO 161
position, however, to be maintained such integrations must stand
in the service of effectual mastery. They serve one of two ends: 1)
utility, or 2) pleasure.
The utility function of a series of coérdinated psychomotor com-
binations does not of itself draw any such large quantum of gratifica-
tion as is absorbed by the objective or end result for which the activity
is instituted. However, when the executive apparatus becomes dis-
abled in some way, not only is the objective spoiled and its gratifica-
tion diminished, but the executive apparatus itself becomes an object
of attention and concern.
In the phenomenon of depersonalization we deal with a new factor.
To these subjects the world appears strange, uncanny, dream-like,
either large or small. Perceptions seem remote; tactile sense is
blunted. These patients do not complain of any change in perception,
but the ideas conveyed by them are altered. Moreover, body feeling
is altered, the subjects appearing strange to themselves and feeling
like automata, with marked changes in affects. This process can be
descriptively represented as a “withdrawal of libido” from experi-
ences in the body ego and the outer world. Schilder (84) sees two
opposing tendencies in this phenomenon: The individual wishes to
retain the integrity of his experiences, and not to “withdraw his
cathexes” from the outer world; on the other hand, he wishes to with-
draw cathexes from the outer world and from the intrapsychic ex-
periences by which they are represented. The symptom is, therefore,
a compromise, quantitatively like the world destruction fantasy of
schizophrenia. However, the ego is still intact enough to maintain
itself apart from the outer world, processes within the ego remaining
still separated from changes in the outer world.
The effective ego has acquired techniques which the infantile ego
at birth did not have. Grossly classified, these functions are percep-
tion (including meaning and use), voluntary motion, orientation,
memory, inhibition and repression. In the functional combinations in
which they are integrated for the practical task of living, these adap-
tive weapons create for the individual a means of security. During the
process we call growth and development, the character of the outer
world and the adaptive mechanisms are constantly undergoing change.
162 THE TRAUMATIC NEUROSES OF WAR
If the transitions are gradual, little anxiety is created; if sudden,
shock reactions are most likely to appear.
The particular form which these shock reactions take is of prime
interest to us. We have already concluded that they take the form of
inhibition of either 1) individual sensory motor organs, 2) specific
completed functions, or 3) compromises between inhibition and ac-
tivity—what may be called partial inhibitions.
This latter conclusion we can permit ourselves from the over-
whelming evidence from hysteria (hysterical blindness), traumatic
neurosis, and epilepsy. This is the method the ego has of freeing itself
from the outer world. When a traumatic experience pierces the pro-
tective mechanisms, the world thus ceasing to be a source of gratifica-
tion, the ego has at its disposal no path to free itself from the hurtful
influence other than along those same channels and means through
the agency of which these mechanisms were originally established.
The ego cannot “repress” the outer world or the demands of the or-
ganism, but it can contract itself, shrink and withdraw. Repression 1s
a technique effective almost exclusively on ideas, impulses and affects
with abundant ideational representability. This shrinkage can take
place partially at single organs or sites, or totally, with periodic ex-
tinction of consciousness. The most universal manifestation of this
type of defense against the insurgency of the outer world lies in the
banality that we go to sleep when we are tired. We thus inhibit most
of the adaptive mechanisms in the sensory-motor and perceptive
apparatus, withdraw them temporarily, and lose consciousness.
This gives us our first clue. We might examine these two phe-
nomena of fatigue (6) and sleep as evidence of ordered retreat from
a situation in which the effectiveness of the ego has become reduced.
In surveying the phenomenon of fatigue it must be noted that it is
a slow reaction to a persistent encroachment on the resources of the
organism. Recuperation is possible with rest or sleep; nothing is
permanently injured.
We have intimated that energy connected with the sensory-motor-
apperceptive-secretory system has as an integral part those organized
portions of the body known as organs. Their functioning is influenced
not only by conditions in the external world that engage their ac-
THE DEVELOPMENT OF THE EFFECTIVE EGO 163
tivity, but also by certain autochthonous conditions resident in the
organs themselves. These conditions are generally known chiefly
as physiological. But since we do not work with physiological assump-
tions of the organ as a datum, and all that it does is to function, we
must assume that these physiological conditions have certain relations
to the personality as a whole and to the problems of adaptation.
The activity of these organs, even according to physiological stand-
ards, has certain normal oscillations which are of two kinds: long
term, maintaining for the entire life trajectory of the individual; and
short term, or diurnal fluctuations. The long term oscillations are
those that maintain for growth of the infant into adulthood (matura-
tion), senility, and death. The short term oscillations are of greater
interest to us.
A clinical fact is that the infant differentiates itself from the adult
in two important respects experimentally verifiable. First, fatigue
is much more rapidly induced in the infant than in the adult; second,
the child’s need for sleep is infinitely greater. These two facts are
intimately related. He needs twenty hours a day of sleep; his muscles
go into a tetanic state with many fewer stimuli per minute. States of
disorganization are, therefore, very easily produced. This is why
the child is, in comparison with the adult, more irritable and more
spasmophilic. The degree of irritability, closely related to fright, 1s
thus an index of the degree of effective adaptation.
The two phenomena that interest us most from the point of view of
“normal” disorganization states are fatigue and sleep. States of dis-
organization can be produced by external traumatic conditions and
by autochthonous factors; in both the internal “physiological” condi-
tions for effective mastery are temporarily destroyed. We must, there-
fore, be prepared to see a reciprocity of the most intimate kind be-
tween the external environment and the internal conditions that
govern the tools of mastery. The external world can remain too per-
sistently traumatic, or the effective adaptations may be disrupted by
internal conditions. In either case we may expect to see phenomena
of disorganization.
In the phenomena of fatigue and sleep we see such normal disor-
ganized states, in which the conditions of mastery are temporarily
164 THE TRAUMATIC NEUROSES OF WAR
destroyed. We cannot enter into the many physiological conditions
that govern these two types of reaction. We realize that there is a
sleep center, and that metabolic changes in the organism as a whole
have much to do with the induction of these two states. These neuro-
logical and physiological conditions do not, however, explain the
entire phenomenon, since it is commonplace that both states can be
induced by purely psychic conditions without the existence of either
toxic or metabolic influences.
Even from the point of view of the psysiologist, fatigue is the
signal of an encroachment upon the reserves of the organism. Owing
to conditions governing the internal environment the energy tone
cannot be constantly maintained on the same level; the physiological
basis of the energy must be periodically renewed by anabolic measures.
Fatigue is thus a phenomenon not unlike pain in its function, in that
it initiates a series of withdrawal and inhibitory phenonmena which
result in a cessation of the excessive drainage of energy.
In the normal individual fatigue has a normal curve of develop-
ment and a direct relationship to diurnal expenditure of energy, 7.é.,
it is proportional to effort. It reaches its height toward evening and is
subjectively not necessarily unpleasant. It is more likely to arise
sooner in connection with efforts that are vain and purposeless and
unsuccessful than with directed, interested, and successful effort. In-
effectual work, stereotypy of attention or effort, too little activity or
too much, not enough motility or too much—all cause fatigue. It is
a reaction to ceaseless activity and immobility, too many impressions
and too few. The absence of fatigue in anchorites, catatonia, catalepsy
and hysterical posture and contractures, represent thus a splitting of
these processes from the ego as a whole.
Whatever be the physiological correlates of fatigue, there is no
doubt of its being a reaction of the total organism. All its psychic
accompaniments indicate a disturbance of the optimal balance be-
tween outer world and ego, with a desire to have done with the outer
world. The psychic symptoms of fatigue are loss of vividness of
sensory impressions, loss of mental tonus and intellectual grasp,
tendency to perseveration, and explosive affective or muscular re-
sponse. In the fatigued state there is both an effort to preserve the
THE DEVELOPMENT OF THE EFFECTIVE EGO 165
normal balance between outer world and ego and the desire to flee it.
The wish to withdraw results in an overstimulation in order to pre-
serve the contact. Ihe boundaries between outer world and ego be-
come less distinct, and in exhausted states the outer world becomes
completely obliterated. There is also a relaxation of normal inhibitory
influences; tired children are irritable, have tantrums, are refractory
and indifferent to punishment.
In certain pathological conditions, like neurasthenia, the subjective
sensation of fatigue is very prominent. These are exaggerations of the
normal fatigue reaction. Most authors agree on the two salient char-
acteristics of neurasthenic fatigue, irritability and weakness. It is note-
worthy that in neurasthenia the course of diurnal efficiency is re-
versed. The efficiency curve and the libido curve coincide, whereas
in the normal individual they alternate. The neurasthenic awakens
exhausted and is at the height of his efficiency when he retires; work
produces efficiency and strength and rest produces fatigue.
The metabolic basis of fatigue need not concern us. This must be
separated from the centripetal psychic reaction that it initiates, whose
purpose is primarily protective. Fatigue may be characterized as a
state of cramp-like inhibition associated with overstimulation. The
inhibitory influences are combated by the increased effort demanded.
The disagreeable sensation associated with fatigue is undoubtedly
the result of the pull and tug of these two opposing tendencies, which
also partly account for its ego-alien character. We cannot enter here
into a discussion of the entire psychology of neurasthenia. Several
things are, however, to be said with certainty about it. Fatigue 1s
actually created by increased effort. This increase in effort is, how-
ever, due to a greatly diminished interest, which in turn is due to
fears of failure. The increased effort represents thus the need to over-
come a strong tendency to retreat from the world.
The twofold character of the struggle to fix attention on the outer
world and to withdraw from it sometimes takes on a compulsive and
distressing character. One patient thus had a symptom that could be
characterized as a form of sticky distractibility. His attention would
become arrested fortuitously by some object in the environment and
here it would remain, stuck in an obsessive and painful manner. His
166 THE TRAUMATIC NEUROSES OF WAR
thoughts would range in a shallow and formal manner about the ob-
ject without being able to proceed with natural spontaneity to the
next. He would look at a chair, be distracted by the fabric, wonder
where it came from, was it made of cotton or wool, how do they shear
the lambs, how is the wool dyed, how do they cut the wood from the
tree, how its it sawed, what do they do with the sawdust, and so on.
It is quite evident that the object had lost all significance to him; but
his obsession represents a futile and frantic effort to endow the object
with some significance. This type of thinking usually terminated in
an outburst of anger, and finally in a manic psychosis.
From the purposive point of view the fatigue of the neurasthenic
has as much justification as anxiety in the phobia. In the latter case the
anxiety is displaced, but its character, source, and connotation justify
the emotion. The fatigue in the neurasthenic is justified in the same
manner; it is proportional to the effort demanded of him to over-
come the pull of his unconscious desire to have done with the world.
To maintain even a tangential contact with the world under these
conditions demands a greater expenditure of energy. The irritability
of the neurasthenic is an indication of the state of disorganization;
it takes less stimulus to overstep the diminished limits of his adapta-
tions. In his sleep the neurasthenic continues his ambivalent state to
the world. His dreams are repetitive; he never gets through with
any action. Moreover, their tempo is retarded. One patient had typical
dreams when he retired in a very fatigued state: the time it took to
consummate any given action was much prolonged, and he was con-
stantly being frustrated. Another, when she had a slight temperature,
which is also a state of diminished capacity to combat the world,
dreamed of actions not completed, and of being subject to endless
frustrations.
Fatigue, therefore, represents a state of disorganization which in-
itiates a series of protective inhibitions and a process of “narcissistic”
withdrawal from the world. The irritability and irascibility associated
with fatigue likewise are indications that the adaptive mechanisms
are disrupted.
The relation of sleep to fatigue is much too complicated for us to
follow out exhaustively here; only a few features must be touched
upon. Under normal conditions sleep is an inhibitory phenomenon.
THE DEVELOPMENT OF THE EFFECTIVE EGO § 167
The conditioned reflexologists have effectively proven this. We
might say that sleep is one of the outcomes of the protective and in-
hibitory processes initiated by fatigue.’
The most obvious thing about sleep is that adaptive contacts with
the outer world cease, and that all processes—sensory, codrdinative
and motor—are temporarily in abeyance. There is a marked drop in
muscle tonus, which can be used as an indicator that the whole attitude
of preparedness for action is reduced.
The conditions of sleep are: fatigue, the shutting out of all stimuli
in the outer world, and an inhibition of all functions that effect these
contacts. Fatigue is not a sime qua non of sleep; excessive fatigue
often prevents sleep. The desire to sleep is generally recognized as
an important psychic condition thereof. That sleep is a protective
and inhibitory phenomenon can be proven by withholding sleep from
animals; the younger they are the sooner they die. In the prepara-
tion for sleep visual sensations are completely shut out, olfactory
sensibility diminished; tactile sensibility reduced to a minimum; the
subject takes a horizontal position with complete relaxation of muscle
tonus. Though auditory stimuli cannot be entirely shut out, habitual
sounds are ignored; unusual sounds, however, preserve their sleep
disturbing properties. The susceptibility to sound is nevertheless
much diminished. Among the internal processes worth noting are the
changes in metabolism and heat regulation. Also interesting to note
is the return of the Babinski reflex during sleep, which Ferenczi de-
scribes as symptomatic of the failure of inhibitory influence of the
cortex and a return of the “spinal soul.”
Sleep as an inhibitory phenomenon is best described by the condi-
* Hibernation (rr) is another of these contractile reactions. According to Leo Adler,
hibernation is a protective device against threatening conditions in the environment.
This reaction is undoubtedly a perversion of ordinary sleep. The hostile conditions which
provoke it are cold and diminished food supply. It is a reaction found only in mammals;
there is no hibernation in fish, amphibia, reptiles and birds, although equivalents of it
occur. In these latter groups various types of lethargic states have been observed, as
well as states of “suspended animation,” but their origin and functions are not under-
stood. In hibernating animals there is a fall in body temperature, and an almost complete
cessation of metabolic processes. There is no intake of food and no voiding of urine.
Most hibernating animals hide in protected places; many of those who fail to do so
die in the hibernating state. When aroused, the temperature rises rapidly; the thyroid
gland, which has in the lethargic state undergone some involutional changes, becomes
much more active.
168 THE TRAUMATIC NEUROSES OF WAR
tioned reflexologists (46). Pawlow originally made the relationship
still more striking in his formulation: “. . . that sleep and internal
inhibition are one and the same thing. Inhibition is a localized sleep
and sleep, a generalized inhibition. Every lasting stimulus which
strikes the cortex and which is not accompanied by or interfered with
by other stimuli, leads to sleepiness and sleep.” Sleep thus takes on
the character of a conditioned reflex. Those dogs are most susceptible
to sleep who are most active and agile and cannot remain exposed to
the same conditions for long without falling asleep. This latter is a
most interesting fact and makes us suspect that sleep is in some way
a disposition of the energy that is prevented normal outlet in activity.
The explanations about sleep vary according to the system of opera-
tional concepts used. If the concept of libido is used, one can say
that sleep is a withdrawal of libido from the outer world. This ex-
planation takes no account, however, of the organs or adaptation
systems by means of which contact with the outer world is established.
It “explains” only the content and ignores the form, and for our pur-
poses the latter is more important. Nor is it of any great help to
think that sleep is a narcissistic process which reproduces the intra-
uterine state.
Our interest in the phenomena of fatigue and sleep is that they are
normal states of disorganization and restitution, and may be of help
in establishing the crucial phenomena of the traumatic neurosis. The
two types of phenomena are not merely analogous, but are similar
processes with marked quantative differences. In fatigue the indi-
vidual knows that the break in his adaptation is purely temporary,
knows how to restore his resources; and in rest or sleep he neither
abandons his interests in the outer world, nor really severs his con-
nection with it, even when the functions through whose agency he
contacts with it are inhibited. It is this divergence which accounts for
the difference in phenomenology. The internal unconscious concep-
tion that the individual has of his own resources remains intact, hence
the conception of the outer world is not permanently altered. The
dreams of the fatigued individual describe how this relationship to
the outer world is changed. An activity is initiated which the dreamer
would rather not consummate; but the objective keeps obtruding
itself on the dreamer, though the means for carrying it through is
THE DEVELOPMENT OF THE EFFECTIVE EGO 169
blocked. It is quite different from the dream of the thirsty man who
drinks enormous quantities of water in a hallucinatory manner to
quench the thirst and remain asleep. The inner tension which we call
thirst may not be satisfied thus, and the sleep is interrupted. The
fatigued dreamer is saying, “I cannot do this,”’ as if thereby to defer
the action. Instead the result is a frustration of the activity in ques-
tion with corresponding anxiety. The dreamer usually wakens from
the dream, and the recuperative réle of sleep is thus miscarried. In-
capacity to carry out action must always be regarded by the ego as
a danger.
The phenomena of fatigue and sleep give us our first definite clue
about what is occurring in the traumatic neurosis. One could even
venture to say that if the energy demands made upon the individual
in the traumatic event were dissipated over a much longer period of
time, the result would be extreme fatigue and not a traumatic neurosis.
The difference between the two is largely quantitative. The qualita-
tive difference lies in the fact that events occur in the traumatic
neuroses which do not in fatigue. Recuperative measures do not have
the same effect in the traumatic neurosis as in fatigue. The reason is
that a protective and permanent inhibition has taken place, effecting
two ends: It has permanently altered the resources of the subject, as a
result of which the outer world has become permanently changed into
a more dangerous place.
SUMMARY AND CONCLUSIONS
Since the argument up to this point has been rather intricate, with
many digressions, a summary would help as an introduction to our
final conclusions and to a consideration of the dynamics of the trau-
matic neuroses.
We began by stating that the concept instinct as an operational tool
was useless in dealing with modalities of activity which can only be
analyzed by a morphological and not with a conative or qualitative
concept. If we grant that activity is propelled by a somatically rooted
drive, we cannot follow disturbances in activity integrations by de-
fining either their quality or their objective, self preservation. The
drive manifests itself in highly differentiated activities whose his-
tory we must trace. Therefore we elected the actton syndrome as our
170 THE TRAUMATIC NEUROSES OF WAR
basic unit, in order to define precisely the techniques of adaptation to
the external environment, from orientation to the most complicated
feats of dexterity and inventiveness.
On close inspection these techniques turn out to be collections of
coérdinated action syndromes. They are not inborn; they are not
elaborations of reflexes; they are not homogeneous. They are learned
and complex, and in man, capable of refinement to a degree unique
in nature. Some of the reasons for man’s plasticity and versatility can
be identified. It is due to the fact that these action syndromes are
not phylogenetically predetermined, but are developed in conjunc-
tion with experience, due to incomplete myelination at birth, a process
not complete until the third year or even later. At birth the capacity
for adaptation to the outer world is zero without maternal aid. In-
ternal automatic functions are relatively complete and subject to some
change (fetal involutions) and stabilization after birth; but to the
outer world a few reflexes, the most important being sucking, and
some disorganized “discharge” phenomena on tension, pain or fright.
Integrative processes begin at the mouth, but even there failure re-
actions can be definitely identified. These integrations are followed
out at eye, ear, mouth and hand. Fusion of optical, kinesthetic and
mnemic elements of pleasant experience can thus be integrated and
become habitual or automatized. Failures cannot be so integrated.
Motility adds a new and complicating elements which alters the
whole external world. The phase of oral mastery yields to manipula-
tion which gradually becomes organized into purposeful activity, ac-
cording as the utility value of the object is appreciated. The process
of delimiting the ego from the rest of the world was described. The
role of the intelligence as master codrdinating apparatus was dis-
cussed, as well as the réle of imitation and identification.
The internal environment—the system of organs and systems
regulating the internal balance—is related to the activity in the outer
world because the conditions for effective functioning are governed
by it. The sympathetic and parasympathetic systems are synchronous
in function with those of the skeletal system. Since the conditions for
action vary, the autonomic system regulates the internal environment
so as to be consonant with these conditions by distributing tissue fluids,
internal secretions and regulating blood pressure and heart rate.
THE DEVELOPMENT OF THE EFFECTIVE EGO 171
These internal activities thus become an integral part of the action
syndrome. The internal environment is not, however, subject to the
same control, inhibition, as voluntary activity. Inhibitions in the latter
system can, therefore, create disturbances in the activities governed
by the autonomic system. These can be regarded from several points
of view as “stasis” phenomena, as partial activities, etc. The rela-
tion between autonomic disturbances and their secondary organic
sequelae, become important orientation points [Alexander (3, 4),
Dunbar (27), French (29) |]. The normal physiological accompani-
ments of anxiety offer a basis of comparison of various types of auto-
nomic disturbances.
The effective ego has, therefore, the following functions: It can
perceive objects in the outer world, interpret them for the special ends
of utility or pleasure, apperception, motility and manipulation capa-
ble of infinite development, orientation, memory, and inhibition (also
repression). In the effective ego these perceptual codrdinate and ex-
ecutive functions are freely mobile, easily accessible for use. There
is one exception, and that is fatigue. This phenomenon is worth study-
ing because it shows us the consequences of slow, gradual encroach-
ments on the executive resources of the ego. It is a “normal” phe-
nomenon in which the internal structure and codrdination of ego
functions is only temporarily disorganized and can be completely
restored by rest or sleep. It is a phenomenon with physiological ac-
companiments. Psychologically speaking it is a tension state which
registers the discrepancy between available resources and the de-
mands on the organism. The symptoms of this state are diminution
in accuracy of perceptions, irritability, tendency to outbursts of rage,
wish to have done with the outer world and to retreat from it tempo-
rarily, without, however, severing the ties to the outer world perma-
nently. The recuperative agent is sleep, a controlled and elastic
inhibitory process.
The reaction to fatigue is not an analogy with the traumatic
neurosis, but a replica, in that the same aspects of the ego are in-
volved, and a similar picture of the sequelae of the process of dis-
organization takes place. There are, however, many differences.
Many of the details of this sketch of development may be incor-
rect, inaccurate, or incomplete; but there can be little doubt about the
172 THE TRAUMATIC NEUROSES OF WAR
allocation of the aspect of adaptation involved in the traumatic
neurosis. There are still, however, some questions about it that we
must answer. 1) What are the concomitants of this development in
the remaining aspects of the personality, and what are their mutual
interconnections? 2) What opportunities are there for arrests of de-
velopment and what are their manifestations? These questions we
must answer in order to come to some conclusions about the relation
of the traumatic neurosis to the personality as a whole, and what is
the relation of the trauma to the pre-traumatic personality, or the
predisposition to the neurosis.
The development we have outlined was described as if it were com-
pletely unrelated to the personality as a whole. This impression 1s
naturally an artifact of presentation. The development of the body
ego and its functions is an integral part of the development of the
personality as a whole, and was isolated temporarily to study its
minutiae. This entire development is associated with the relations to
the parent, to the culture which regulates the social control of im-
pulses, and furnishes the limits of this development as well as some
particular techniques which are there in vogue.
From the very first experiences at the breast, the infant can have
severe frustrations, and at this time the utility value of the mouth
as a feeding executive, and the pleasure value of sucking are intimately
fused. These two functions of the mouth, the utility and pleasure
value, mutually influence each other. If the pleasure value of the
mouth is predominant it is likely to lead to strong attachment to the
mother, which is likely to exert a retarding influence on the develop-
ment of adaptation to the outer world. Disappointments in these
encounters with the outer world are likely to increase not only the
pleasure value of the mouth but the ego attitude of dependency, an
attitude which strongly influences the reactions to disciplines later
instituted. This in turn diminishes the self confidence of the individual
and lessens his enterprise.
The process of weaning and the induction of sphincter control are
likely to act as stimulating and retarding influences; in fact any situa-
tion that compels the child to alter established adaptations is likely
to meet with protest. On the other hand new contacts afford new
THE. DEVELOPMENT \OF THE EFFECTIVE EGO 172
gratifications if they are successful. The character and time of induc-
tion of the weaning are likely to have a marked influence on the
building of action syndromes, especially the rapidity with which they
develop. The induction of sphincter control, weaning, and beginning
of locomotion all take place within close proximity, and a more con-
centrated collection of new experiences never occurs again in the
whole life cycle of the individual. In connection with this develop-
ment many things occur which are still very obscure. Children whose
encounters with the outer world are filled with frustrations are likely
to resent these changes, to which they are propelled both by growth
and the demands of the social environment (parent). This attitude
of resentment yields to social control with development of special
attitudes to both the activity and the disciplinarian.
_ Of particular interest in connection with ego development is the
precocity of sexual activity of the child. This relationship is, how-
ever, still very obscure. It is possible that the pleasure function of
the sexual activity acts as a releaser of tensions created by encounters
with the outer world. In this case the social control of masturbation
in childhood both by direct and implied methods has a retarding in-
fluence.
In addition to the rdle of imitation and identification there is the
important factor of direct parental aid in development. Left to its
own resources it follows that the child will be subject to innumerable
disappointments and shocks. If the child can be spared many of these
by anticipation or by immediate help inhibitions and their sequelae
can be prevented. This has been proven on identical twins by McGraw
(63), where one child was given great assistance in the development
of activities, and the other neglected. The former developed with
great rapidity; the neglected one was very far behind. Furthermore
the relation of this development to other social situations as rivalry
and competition, etc., is a long and intricate subject [Murphy (68),
Levy (56, 57) ].
No individual can be studied with any care without revealing a
series of characteristics which bear the imprint of minor inhibitions
—like distaste for sports—which are part of his individuality. Such
inhibitions, usually disguised as distaste, lack of interest, or per-
174 THE TRAUMATIC NEUROSES OF WAR
sonal idiosyncracy, can exist without impairing the general effective-
ness of the individual. But they all have the structure of minor trau-
matic neuroses. The reverse is also true; the history of special apti-
tudes and dexterities follows the lines of integration in the line of
successes, with increased meaning accruing with each success. The
ultimate result is the expression of skill, and the techniques in the
manual arts. There can be little doubt that in the skills of the graphic
arts there is a body ego component in the fact of greater meaning of
form and color. The concept “sublimation” only explains the qualita-
tive element.
Another important connection that body ego development has to
the personality as a whole has already been explored in the study
of hysteria. Here, as Freud (38) pointed out, the utility function
of the organ or limb, yields to its erotic significance. Inhibitions of
this kind are not, however, of the kind we encountered in the trau-
matic neurosis. They proceed from a significance of the organ to those
factors in development which are socially governed directly, or
through its internalized representative, the superego.
Furthermore gross inhibitions of all action syndromes effective in
work can occur, for reasons that have nothing to do with the develop-
ment of the actual ego functions. Thus one patient had a work in-
hibition which showed itself in a complete inefficiency when he at-
tempted work and great anxiety in anticipation of failure. The crucial
constellations in this neurosis were not based on failures in develop-
ment of action systems, but in the uses to which they were to be put.
He never took a responsibility for himself in his entire life. His re-
lations to others were predicated by the assumption that his helpless-
ness was a claim for help, and that he had the same claim on everyone
that he originally had on his parents. This is an instance of inhibitions
of ego functions based on a persistence of infantile relation to others.
His neurosis, however, had no resemblance to a traumatic neurosis.
It was not a body ego problem; this was intact. But the uses in which
his action syndromes could be effective were strongly under the in-
fluence of childish attitudes in his relation with other individuals.
In short the body ego development has many connections with the
other aspects of the personality. The utility function of organs and
action systems do not fall under superego supervision, that is, social
THE DEVELOPMENT OF THE EFFECTIVE EGO 175
control of impulses and their internalization. The only aspect that
falls under social control is the use or disposition of these body ego
functions, the most notable of which is aggression to others. They de-
velop under the limits permitted by external reality, and the actual
capacities of the body ego and intelligence. Furthermore this develop-
ment always takes place in a cultural mould, and is predicated by the
patterns extant in the specific culture, apart from the general func-
tion of orientation, manipulation, and motility. The turbine was not
invented by a native of the Marquesas Islands.
A second question is whether the development of the body-ego
is subject to the vicissitudes of fixation, repression, regression, return
of the repressed, and if so what are its manifestations? This is another
way of stating the problem of the predisposition to the neurosis. To
start with these criteria mentioned apply to the conception of neurosis
couched in the terms of instinct and are not adapted to a morphological
operational concept.
Arrests in the development of the body-ego functions do take
place. They are not, however, likely to be noticed because in most
instances failures can be compensated for by abandoning the failure
and pursuing success. Except for the basic functions of orientation
and locomotion, there is a wide range of choice. This circumstance
can lead only to the development of one aptitude as against another.
This is not similar to displacement or regression.
The only kind of arrest of development which is likely to be
noticed is one that is general and involves the most elementary forms
of adaptation, and even there this development is likely to be re-
tarded or incomplete. Ne do not yet have any reliable criteria for
detecting these arrests. In the sexual domain the arrest of develop-
ment takes place largely as the result of social control of impulses.
Such social control is not exercised in the intrinsic development of
the body-ego; on the contrary the development is encouraged to a
greater or lesser degree, though it is channelized into socially ap-
proved directions.
Retarding influences can come from general organic defects like
those leading to mental deficiency. This is not of great importance.
The only other detectable influence is a trait for which no name yet
exists, but which can be described as incomplete mastery. The mani-
176 THE TRAUMATIC NEUROSES OF WAR
festations of this kind of arrest were described in the case on p. 190.
The arrest showed itself in slow and inadequate mastery. This child
was constantly falling down, never ceased the activities of destructive-
ness, like boring holes, tearing and breaking her toys. Eventually
she became an epileptic. But these destructive traits showed them-
selves in her from the third year onward. Following the later trau-
matic experience, there were regressions to activities and play aban-
doned seven years previously. In the traumatic neurosis adaptation
corresponding to oral mastery and destructiveness have been de-
scribed, In other cases actual reproduction of adaptations correspond-
ing to the first months and first year of life have been repeatedly
noted.
These regressions cannot, however, be harmoniously integrated
with the same success as they are in the other neuroses.
The answer to the question of predisposition cannot be completely
given now. It is a predisposition not dissimilar to that for epilepsy.
If therefore we look for the predisposing factors in the pre-traumatic
personality we are not likely to find anything distinctive. Data like
those of persistent destructiveness in childhood are not likely to be
remembered, and I have never had the opportunity to study the
personality of a subject who later developed a traumatic neurosis.
In the actual subjects with traumatic neurosis we find three varieties
of personality: 1) those in whom the trauma is woven into the char-
acter structure, in which the trauma has the significance of punish-
ment or longing for a protector; 2) those in whom psychoneurotic
symptoms and traumatic neurosis coexist, so that if the traumatic
neurosis 1s removed, the other becomes more prominent (p. 19);
and 3) those in whom the traumatic neurosis is the exclusive picture
(see p. 46). In each of these cases the traumatic neurosis as described
is always present. In this volume the third type was the one studied
exclusively. The other types still remain to be investigated. This
physioneurotic syndrome is present in all cases following traumatic
experience, whether the reaction lasts three hours or thirteen years,
and irrespective of the pre-existing personality, be it schizophrenic,
psychoneurotic of “normal.” The differences are to be found in the
failure of recuperation, the persistence of the neurosis.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
V. PSYCHODYNAMICS
HavING STUDIED the body ego and its action syndromes we are 1n a
position to track down the changes responsible for the symptoms and
other manifestations of the neurosis. For this purpose we can study
1) the differences between inhibited and uninhibited activity; 2)
the structure and relations of the action syndrome, or at least identify
its constituent elements; 3) We can then identify the elements in-
hibited; 4) and finally follow out the consequences of this inhibition.
STRUCTURE AND RELATIONS OF THE ACTION SYNDROME
From the study of the transference neurosis we learned that when
there are no obstacles between an impulse and its execution, the ac-
tivity leads to release of tension, gratification or pleasure. When the
impulse arises again, there is an anticipation of gratification, a mobili-
zation of executive functions, and their psychic counterparts or
memory pictures. There is formed, as a result of such successes, a
picture of oneself as consummating the activity. This is positively
toned affectively and gives rise to the attitude commonly known as
self-confidence, and is expressed in the formula, “I can do that.”
This leads to a confident, friendly and eager attitude to the impulse
when it arises again and to pleasant anticipations. It is represented in
word, idea, and motility constellations which are easily accessible,
plastic, and mobile.
When the element of pain in the form of anxiety is introduced into
activity by social control, the parent, through threats of punishment
or loss of protection, conditions are created which favor the abandon-
ment of the pleasurable activity as an escape from the situation and to
preserve the dominant interest. Should such an impulse arise again,
instead of a friendly attitude, there is one of anxiety, which 1s the
anticipation of danger. In fact, anxiety may appear instead of the im-
pulse after the latter has been repressed. Instead of an attitude of
confidence, there is timidity, fear of the forbidding parent, increase
178 THE TRAUMATIC NEUROSES OF WAR
in dependency to him. If the repression is complete, we now have
what is called an mhibition. Such an inhibition modifies the entire
executive apparatus. The perceptions of oneself and of the activity
become modified, so that the impulse is represented not in its original
and pleasurable form, but by its opposite, cruel and hurtful (masoch-
istic) images. In dreams the individual represents himself as failing
in gratifications. This represents a complete change in the organiza-
ion of the personality.
If the impulse in question is a sexual one, the occurrences follow-
ing the inhibition are due to the nature of the impulse and of the
capacities of the organism to accommodate to this socially imposed
control. Since the end desired is a type of sexual pleasure, and the
orgastic experience is the one sought after, two modalities in the or-
ganization of the personality are possible in order to achieve that end;
there is the active masculine, and passive feminine. In the latter case
the end result, the orgastic experience, may be impaired but it does
not always follow. Another factor aids to the possibilities of adjust-
ment to this primary inhibition, namely, the possibility of pressing
other zones than the sexual into erotic use, as the mouth, anus, etc.
Thus an inhibition established early in life has the possibility of form-
ing a new adjustment by displacement, regression, and the reorgan-
ization of the personality from an active to a passive modality. This
latter process gives rise to what are called masochistic phenomena.
Needless to say, sexual tensions cannot always be adequately expressed
through this masochistic organization and the orgastic experience
may even fail. On the other hand the orgastic experience may be ade-
quate, but the relations to the sexual object seriously distorted. The
result is neurosis of the transference type. The manifestations of this
neurosis are, therefore, predicated by the particular impulse in-
volved, and by the possibilities through changes in organization to
bring some equivalent for the normal consummation to pass. In bring-
ing this result about the possibility of passivity and of regressive dis-
placement have played a signal réle.
In the traumatic neurosis we are dealing with modalities of activ-
ity in back of which we predicated a drive. We cannot, therefore,
identify any specific instincts, nor any instinctual goal; but we do
PSYCHODYNAMICS 179
recognize the goal of mastery. The activity itself has a structure we
must describe in order to be able to understand what happens when
we speak of an inhibition.
There are three aspects to the action syndrome, corresponding to
receptor, codrdinator, and effector apparatus. No schematic repre-
sentation does justice to the actual events, and our scheme hardly does
more than to identify the constituents.
Perception by sense organs and coérdination of past experience
gives meaning to objects in the outer world. The chief of these 1s
utility. The objective is to exploit, avoid, manipulate, use, destroy
or render ineffectual, all of which intends to circumvent the peace-
disturbing properties of the object. The affective attitude is one of
interest, which together with other codrdinators gives rise to impulse
to investigate (curiosity). The actual executive is the motor apparatus,
through muscular codrdination of memory pictures, visual, kin-
esthetic, aided by the knowledge of past success. These are freely
accessible for use when the proper stimulus arises. Moreover, they
are modifiable, leading eventually to skill. Together with curiosity
this composition makes for inventiveness. Coincident with these motor
activities there are a series of autonomic accompaniments, attuned
to activity of the executive system, and ready to alter the internal
organization in response to need.
The effect of the consummation of this activity is the creation of an
attitude of self-confidence, enterprise, expressible in the formula, “I
can do that,” a feeling of pride, ego enhancement, or merely satisfac-
tion.
The control of this whole action syndrome is vested in the balance
between the external reality (reality testing) and the resources of
the organism as a whole. The efficacy and smooth operation of the
action syndrome is brought into question in fatigue, or when the
stimulus is too overwhelming, which disturbs the balance between
ego and outer world.
Now we need to study what happens in the acute traumatic event.
From the fright reactions of infants we learned that no ego could be
formed in an environment that remained persistently traumatic. The
work of the reflexologists supports this view. Furthermore, it is high-
180 THE TRAUMATIC NEUROSES OF WAR
ly probable that in infants the perceptive element in the traumatic
stimulus is almost completely absent (9). These two facts can be
verified in the traumatic neurosis; the ego becomes disorganized, the
sensory elements of the trauma are perceived only to a slight degree,
and if the stimulus reaches a sufficient degree of intensity, conscious-
ness is lost entirely. It is no exaggeration to say that in this moment
when consciousness is lost all organized responses are cut through,
and the retreat in the form of ego shrinkage can be so complete that
death can and occasionally does result. In addition, an enormous dis-
organized aggression is released. This means simply that the in-
dividual is trying to maintain contact with the outer world without
the aid of the organized, integrated, and orderly techniques. It means
also that the significance of the outer world must change from a
friendly to a hostile place. In the transference and narcissistic neuroses
the breaking of organized adaptation is a relatively slow process,
where the ego has more or less chance to re-establish new adaptations
on another level by means of regression, always a cushion against
which the ego can fall. Regression thus prevents the complete over-
whelming of the ego.
In the state that follows a severe trauma we may have an actual
reproduction of the conditions of infancy. Consciousness is either com-
pletely lost, or the sense organs and motor and perceptive ap-
paratus are much diminished in capacity. Only the most primitive
vegetative functions remain active. That this is a process of with-
drawal and not one of being overwhelmed in a physical sense, is sup-
ported by the observation that many such severe states were seen
in subjects who only anticipated a trauma that did not actually occur.
This type of reaction is entirely centripetal in character. In general,
the reaction is like the contraction of the pseudopodia of an amoeba.
Since the organism cannot contract, however, it withdraws the adap-
tive mechanisms, with the result that either individual manipulations
fall away or the organs through which they are executed are para-
lyzed partially or wholly. In fact, in many cases the post-traumatic
adaptation cancels out all those integrated activities which took place
after birth. In the delirious reactions the ego is fragmented beyond
recognition, and all experiential connections which make the world
an ordered place are lost.
PSYCHODYNAMICS 181
Following this initial loss of consciousness, which is extremely
variable in duration, the state of infantile adaptation is reproduced in
some respects. There is hypersensitivity to all stimuli and a persistent
effort to keep the outer world away, for its meaning is now lost.
Then follows a period in which readaptation is attempted, and
here lies the crux of the traumatic neurosis. In some subjects, for
reasons that we shall subsequently discuss, this readaptation takes
place normally. This is the period in which all traumatic subjects
have nightmares of destruction; but some go on to a complete re-
habilitation and others remain stuck in this reduced position (see
convalescent dreams on p. 91). In these latter cases the factor that
interferes with the rehabilitation is a series of systematized inhibitions,
entirely unconscious, and more or less uniform in character. This is
where the pathogenic factor lies. We have seen that this ability to
inhibit unsuccessful modes of adaptation is the one responsible for
the very growth of the integrated ego, and here we find it inter-
fering with the entire adaptation of the individual. In the infant
who burns himself in the candle flame, in the animal which is disap-
pointed in his conditioned reflex, in the man who falls from a horse
and is then afraid to mount any horse—in all these we see the same
principle. But in the case of the traumatic neurosis the protective
function of inhibition seems to have miscarried; no more so, however,
than in the case of the transference neurosis, where when a given im-
pulse is inhibited, it is from that time on lost to the ego as a whole.
This same is true of the traumatic neurosis, but in the latter the inhi-
bitions are more costly to maintain, and more damaging to the total
adaptation than are the localized inhibitions of hysteria, and the
greater opportunities for compensatory devices that exist in the latter.
In the normal process of growth any number of petty traumata are
experienced, which induce localized inhibitions and which the indi-
vidual overcomes by easily available substitutes or alternatives. This
choice is not open in the traumatic neurosis, for the trauma in the
adult strikes a fixed structure, the usefulness and expediency of which
has been demonstrated by many successes in the past. The adult has,
therefore, much less plasticity than the growing child. However, a
traumatic neurosis in a child has the same arresting effect.
Before we can appreciate the effects of the inhibitions in chronic
182 THE TRAUMATIC NEUROSES OF WAR
cases we must first know what is inhibited. The sense organs generally
continue to function, and apparently the pictures of reality they report
are formally quite the same as before; they may episodically blurred
and confused. But their meaning has been modified, because the
manipulative or mastery elements are no longer effectual. The ob-
jective of action with regard to them is seriously impaired or lost.
Hence there is a wish to have done with the outer world, and get
away from it. The former interest and curiosity is replaced by an atti-
tude of vigilance, anxiety, and above all irritability.
The effectiveness of the actual motor system is greatly impaired,
and in localized places entirely paralyzed. This leads clinically to
awkwardness, tremors, vertigo, stumbling, fumbling, etc. The free
accessibility of the motor functions is lost. The autonomic system is
active, but not in consonance with the demands of reality, the effective
motor channels now being blocked in whole or in part.
Thus when an impulse for action arises in this now altered organism
instead of eagerness and curiosity, there is irritability and prepared-
ness for flight. The self-confidence is gone, and the individual ulti-
mately gets a permanent picture of himself as helpless. He cannot
conjure up the picture of a completed action, and can get no satisfac-
tion from his ineffectual efforts.
THE CONSEQUENCES OF THE INHIBITION
In the transference neurosis we noted that the consequences of
inhibition were that an entirely new reorganization of the personality
occurred, In these neuroses the process was facilitated by the ability
to press other organs or zones into use for the one abandoned, and
by alterations of the modality of the entire personality from activity
to passivity.
These possibilities are not open in the traumatic neurosis, because
of the particular aspects of the ego that happen to be involved. The
needs of the organism for contact with the outer world can only be
silenced by death, and the insurgency of the outer world continues
and can not be done away with. Hence repression and substitution
are impossible. Regressions can and are instituted; but they are of
little avail in maintaining a satisfactory contact with the environment.
PSYCHODYNAMICS 183
In this category are the “oral mastery,” which clinically takes the
form of destructiveness, and the gross reinstatement of the behavior
of infants. No release of tensions can be achieved by these regressive
means. No displacement is possible, because the effective ego, and the
various components of the action syndrome have fixed functions,
intimately tied to the physiological functions of the executive appa-
ratus. Such opportunities for choice as there were in the course of de-
velopment, have already been exercised, and the organism subjected
to the trauma no longer has the opportunity to build new action
syndromes. This is especially so since the functions involved are the
most elementary. In short no substitution or displacement is possible.
Secondly the modality of passivity is likewise untenable in adap-
tation to the outer world. This is possible in interpersonal relations,
to a superior whose favor and protection one wants to preserve. But
what is passivity to the outer world? The only recognizable form is
death; because complete passivity means that the world is permitted
to overwhelm the subject. The concept passivity in this connection
is incompatible with any effective adaptation. When an impulse is
abandoned under the influence of a parental threat (social injunction)
and maintained by the internalization of this force, the superego, it
must be remembered that the tonicity of this internal force is main-
tained by the expectation that the rewards for repression can still be
realized. In the case of the traumatic neurosis no such relationship
between ego and outer world exists as corresponds to the one between
parent and child. The contraction of the ego was not here enforced
by a social sanction or its later representative, the superego, but by
the discrepancy between the forces in the outer world and resources
of the ego. This principle has been operating since birth in the indi-
vidual, and the whole effective ego owes its effectuality to its agency.
Since introversion or displacement are impossible, the functions
through whose agency effective contact with the outer world is main-
tained shrink, or contract. They maintain a minimal contact with
the world, a contact whose quality is now much altered.
Contraction of the ego, with consequent inhibitions, is a process
that can be identified in the executive portions of the action syndrome.
By certain sensory codrdinative elements, the memories of the event,
184 THE TRAUMATIC NEUROSES OF WAR
are subject to repression. There is not only amnesia, but persistent
resistance to their recall. This is a defense against the renewal of the
painful experience, to be sure. It can be definitely shown that (see p.
221) this amnesia is only a symptom of ego contraction and not its
cause; for once the inhibitions are lifted and functioning reinstated,
the amnesia lifts, as does the resistance. We never hesitate to recall
painful experiences if their effects are no longer current.
Once these contractions are established, we can evaluate the re-
maining phenomena according to the a) changes in effective adap-
tation, b) changes in the conception of oneself, c) changes in the
perception of the outer world, and d) changes in autonomic activities,
and other characteristics, such as dream life and outbursts of aggres-
sion.
a) The new adjustment is erected on the ruins of what was once
arich reciprocal relation with the outer world. The ego is now smaller,
in the case of the sensory motor paralyses, and for all the other types,
impoverished. The quality of its contacts with the world are coarser,
and the individual is always on the verge of wanting to get away
from it.
The most important clinical evidence for the reduced resources is
the diminished capacity for work. Effective work means the codpera-
tion between all executive functions and an interest in the world and
in the objectives for which the work is done. These executive functions
are now disorganized. The motion harmonies lose their accuracy and
smoothness. I’he meaning of the objective is clouded and indistinct.
This failure of organized channels of aggression is to be equated with
the periodic outbursts of disorganized aggression so characteristic of
all these neuroses.
band c) The endopsychic conception of one’s own person has also
undergone a marked change, not a feeling of inferiority, at least I
have never heard that complaint. But confidence is destroyed, and
retreat instead of enterprise becomes the objective. Coincident with
this change is the change in the meaning of the outer world. It is
now a hostile place, and the subject feels in constant danger of being
overwhelmed by it.
It is the change in the conception of oneself and the outer world
PSYCHODYNAMICS 185
that is responsible for the catastrophic dreams. The catastrophic
dreams either fail to carry an action through to completion or they
end in failure. This means that the ego structure of the individual
has been altered, so that the weapons with which to carry the action
through are no longer a part of the effective ego. The idea that the
world is caving in on the subject is warranted by the fact that those
instruments with which the world is kept at bay—all organized ag-
gressive activities—are no longer enjoyed by him. He is not their
master, and he no longer enjoys their protection. Hence the endo-
psychic perception of a hostile world and an impoverished self. An
extremely vital point is the significance of the disorganized aggres-
sion.
The catastrophic dream is a challenge to the general formula that
dreams represent wish fulfillments. This dream contradicts this gen-
eral idea. I believe that the difficulty lies not so much in that it 1s a
contradiction of the theory but in that this formulation of the dream
functions may be at fault. ““Wish-fulfillment” is a rather confusing
characterization of dream function. If one examines a dream from the
point of view of wish fulfillment, one can usually find some wash. But
most often the manner in which it is handled is more important than
the wish itself. If we study the dream of a frigid woman in which she
sees herself in bed with her paramour, but her mother comes in with
a tray of food, and the patient has the affect in the dream of anger,
we have some difficulty locating the wish. One can say the dream
satisfies the wish for oral satisfaction instead of genital. I do not be-
lieve this to be the case. The subject is giving us information primarily
about the structure of her personality. It tells us that the sexual wish
is interfered with by something which has attributes of mother and
of eating. The dream of the traumatic neurotic is no different. It gives
us information about the structure of his new personality, established
on the ruins of what was once an effectual system. The subject starts
many activities but cannot consummate them. This tells us merely that
he cannot carry out any activity and the wish is not even formulated.
The reason for this we know, but our subject does not. How can he
carry out any activity if he has lost the instruments with which to do
it? Why can’t he deny all this with pleasant dreams of effectiveness?
186 THE TRAUMATIC NEUROSES OF WAR
The subject is vaguely aware of his diminished resources, and the
discomfort and anxieties are too great to be overcome by fantasy, in
the same way that a dream of drinking water most often terminates in
waking the sleeper, notwithstanding the intention of the dream to
preserve sleep by satisfying the wish for water.
We could say from these catastrophic dreams that the subject now
has adopted an extremely masochistic attitude to the world; from the
outbursts of aggression we might say that the adaptation is extremely
sadistic. Neither characterization is very informative. He is not seek-
ing gratification of a sadistic impulse. Both phenomena are conse-
quences of the underlying inhibitions. This is the basic pathology; the
rest are efforts at re-establishing a meaningful contact with the outer
world.
How does the inhibition explain both the masochistic phenomena
and the aggressive? In the first place both these concepts cannot be
used in the same way as they were in the transference neuroses accord-
ing to the libido theory. In this new context this description does not
make sense, and it may be that the original theoretical formulations
were derived from the difficulties attending the use of mstinct as an
operational concept. The whole situation appears much more clearly
and simply in the traumatic neuroses. We started by stating that we
had to employ a morphological unit, the action syndrome, and not a
conative concept like instinct. Therefore instead of asking what m-
stinct is involved, we ask what action syndromes or parts of them are
involved. From the point of view of instinct, sadism and masochism
had to be considered attributes of the imstinct. This view is being
changed. Masochism is a type of ego organization with respect to the
use of certain ego resources. The phenomena studied in connection
with the sexual impulse do not apply to the body-ego action syndrome.
In the first case the masochistic attitude is one maintained to another
individual. This can become habitual and so organized that pleasure
qualities can not only be attached to masochistic activities but become
an indispensable factor—provided the ultimate goal be achieved, or
if the expectation of its realization can be maintained. In the case of
the action syndrome we predicated a drive. But we were not examin-
ing the drive which we could not get hold of; we could only see the
PSYCHODYNAMICS 187°
action syndrome. Therefore whatever manifestations followed either
highly organized and successful activity, or the products of the break-
down of these action syndromes, we could still predicate that in both
cases the drive was the same, and that what was altered was not the
drive, but the ego organization. The same view can be used for the
sexual masochism as well.
If we attempt to describe the adaptation in the traumatic neurosis,
especially the catastrophic dreams or the outbursts of aggression, on
the basis that it is a masochistic phenomenon, we cannot quarrel with
its descriptive value, but it gives no indication of where the trouble —
lies. The subject does not wish to be overwhelmed by the world—
there is no orgastic anticipation or Nirvana principle in back of this
attitude. On the contrary he is trying to establish a meaningful contact
with the world that has been ruined by the traumatic experience. By
the same token the outbursts of aggression are not merely regressive
phenomena; they have the same meaning now that they did in child-
hood, when they were clearly evidence of disorganized or incomplete
forms of mastery. It follows that if the need tensions continue—and
they will as long as our subject is alive—he will seek satisfaction
from the world one way or another. When the organized forms are
not available, we find these outbursts of aggression. Hence the ques-
tion as to whether they are regressive phenomena or disorganized
is purely academic. The only difference between infantile aggression
and that of the traumatic neurosis is that in the former the child has
a sense of accomplishment and triumph. Not so in the latter; there
they are paroxysms of frustration and inadequacy. This technique is
totally incompatible with his current needs,
Masochistic phenomena in social and sexual adaptation of man are
indicators of great changes in organization of the personality. But they
are in themselves not incompatible with life, and if started early
enough in the life of the individual can even be worked into a form
yielding particular gratifications. They are not, of course, in accord-
ance with the general social ideal. Masochistic adaptation to the
outer world cannot ever yield any gratifications. The only adaptations
that can do so are the secondary uses to which this state of affairs can
be put, namely to claim compensation. But this is not a primary gain;
rs THE TRAUMATIC NEUROSES OF WAR
it is a secondary gain. It is the use to which the now reduced status is
put. It is moreover a type of adaptation in which direct encounters
with the outer world are evaded; it is now established on the same
basis as the infant, through the agency of another person or institu-
tion—a form of neurotic parasitism.
We can summarize by stating:
The traumatic neurosis has furnished us the first opportunity
to test the operational value of the concept “masochism,” as it
was worked out in hysteria and compulsion neurosis. It is quite
evident that the modalities “activity” and “passivity” do not
function with equal degrees of success in all aspects of ego or-
ganization. For it can be said with certainty that “passivity” in
sexual adaptation, be it in male or female, retains a good deal of
the same quality as “activity.” This is not due to any innate “‘bi-
sexuality” of man, but to the fact that the pleasure quality of
sexual gratification can be achieved through various types of ego
organization with perhaps only minor changes. Ego functions
other than sexual are capable of no such organizational changes
without suffering, at the same time, drastic changes in quality.
The reason seems to be that the gratification they achieve is not
direct, or only to a smaller degree. That is essentially what we
mean when we call the function they perform a wiility function
and not a pleasure function.
Several points now become clear from these considerations:
1. Masochism represents primarily a state of ego organization
in pursuit of a drive, and not the drive or the “instinct” itself.
The concept “death instinct” is decidedly misleading in this
regard.
2. Ego organization can be so altered by inhibitions as to com-
pletely disturb the utility function of certain organs or action
systems. And it is this which is responsible for the structure
of the catastrophic dream. If we must predicate “drives,”
then we must conclude that the “drive” remains unchanged.
What is altered is the ego organization necessary to execute
the “drive.” The catastrophic dream, therefore, records an
attempt to execute a drive with an ego organization shorn of
PSYCHODYNAMICS 189
its implements. The utility function of this organization is
now defective. If we conceive of the effective ego organiza-
tion as a means of “pushing” the world away, of limiting
the character of this contact by manipulation of some kind,
then once these functions are impounded, the endopsychic
perception is justified that the outer world is overwhelming
the subject. This may be diagrammatically represented as
follows:
Outer world Outer world
Ego Ego
Effective Ego W/
Contracted or
Collapsed Ego
FIGURE 1.
The repetitive character of the phenomena in traumatic neurosis
is again a misleading observation. They are indeed repetitive, yet
repetition is no active principle. This statement hides the fact that the
ego organization has been altered; the patient’s now operating within
confined limits of his shrunken ego gives the impression of repetitive
phenomena. His activities are no more repetitive than are those of a
prisoner in a cell which contains nothing but a chair. The character
of the traumatic neurosis is no more repetitive than that of the ordi-
nary neurosis—or the normal individual. They look repetitive because
on each occasion that a bit of action is initiated, the same blockage is
encountered, with the resulting failure.
The last two phases to be considered are the autonomic phenomena
and the behavior of these patients to compensation.
The autonomic phenomena need to be explained as regards their
role in this failure reaction which is the traumatic neurosis. We have
seen that at times this autonomic aspect may occupy the entire facade
190 THE TRAUMATIC NEUROSES OF WAR
of the neurosis. These autonomic phenomena may be considered “‘dis-
charge” manifestations. One may say that the inhibitions above de-
scribed produce stasis phenomena, on the principle that since the de-
mands of the external world continue to be the same as those before
the neurosis was established, and the executive apparatus cannot carry
out the necessary adaptive manipulations, that stasis of some kind
will accumulate. In other words it is as if the internal environment
were geared for action, and the executive apparatus not. Hence
autonomic activity, which is shunted from its proper function, con-
tinues unaccompanied by the activity of which it was originally an
integral part. Bieber and Tarachow, in an unpublished paper called
“The Autonomic Symptoms, A Part of the Action Complex,” state
that autonomic phenomena are “integrated parts of the action complex
at the moment of efforts at mastery under the given neurotic vicissi-
tudes.” This view is not at variance with the one proposed, because
“the moment of mastery” in the traumatic neurosis is continuous and
ever present, with periodic exacerbations.
In the traumatic neurosis the place of the autonomic system in the
action syndrome is quite clear. It stands in direct relation to activity
which is inhibited and in this neurosis is a part of the disorganization
phenomena. The relations of autonomic disturbances in other neuroses
are more difficult to disentangle. A rich literature has grown about
this aspect of neurosis which promises to be of the greatest significance
(Alexander, Dunbar, Felix Deutsch, French, Daniels, Cobb, e¢ a/.).
In this work certain somatic syndromes like gastric ulcer, mucous
colitis, asthma, hypertension, are studied as expressions and outcomes
of certain emotional conflict situations. Little question can be raised
about the phenomenological aspects of this work; this can arise only
in the interpretation of the facts, and here the definition of the precise
relation of the autonomic disturbance or its secondary sequelz to the
emotional conflicts is not easy.
The patterns recorded are of several varieties; those pertaining to
the gastrointestinal tract are such that these organs are pressed into
the services of the ego as a whole, by the perversion of some of their
known utility functions. These functions are largely devoted to the
internal environment and have little (they do have something) to
PSYCHODYNAMICS Ig!
do with activities to the outer world. Contractive, secretory, retentive,
expulsive functions may thus be exaggerated, in order to consummate
some unconscious purpose of the ego. A second variety, hypertension,
is concerned with inhibited “aggression.” A third, asthma, is related
to behavior control in connection with sexual and other situations.
In evaluating the observations recorded by these authors it must
be borne in mind that the specific conflicts, and the personality pictures
can all be found without the particular somatic accompaniments of
colitis, peptic ulcer, hypertension or asthma. Hence we must answer
the question of what are the differences between these two types of
cases. This problem is not solved yet, nor is it likely to be solved by
merely correlating the psychological picture with the somatic events,
though this is an indispensable step. There are some intervening steps
that need to be isolated. All these phenomena of colitis, peptic ulcer,
asthma and hypertension, and a host of other miscellaneous autonomic
disturbances have been noted in the traumatic neurosis, where the
nature of the conflict is quite different from those recorded in the
character neuroses. There are apparently two separate problems in-
volved: 1) the structure of the specific action syndromes involved
and 2) the uses to which this action syndrome is put by the personali-
ty as whole. For example: there is a specific somatic picture that ac-
companies anxiety. In the creation of this picture there is a definite
relation between the affect and the action to be undertaken for the
danger situation. This action may not be possible because the danger
stimulus is too great, or the action be inhibited. In either case free
access to effective activity is blocked. In some individuals this normal
physiological anxiety picture is altered; in fact it may not even be
perceived as anxiety; but instead some of the autonomic phenomena
be distorted in one direction or another. More precise definition of
these relations must wait for a finer appreciation of the relation be-
tween anxiety and motor inhibition. Once this particular type of action
syndrome is formed, the individual will use it on any occasion of
anxiety. This is where the differentiation beween the two types of
cases seems to lie.
In the case cited by French (J.c.) the patient abandons a sexual
temptation for fear of losing parental protection if he does so, This
192 THE TRAUMATIC NEUROSES OF WAR
constellation, “if I do this I will be punished,” is a persistence of an
infantile reaction to discipline. This is not what is related to asthma;
this can be found in any hysteria or obsessional neurosis. What is spe-
cific about this reaction is that in association with the anxiety a special
somatic system governed by the automatic apparatus goes into
spasm, This is a specific integration of action syndromes, and is a per-
version of the normal anxiety picture. From the traumatic neuroses
my feeling would be that this physioneurotic reaction is related more
to the motor inhibitions than to the affect. This is quite obviously the
case in hypertension. If we can permit a guess, we might say that in
hypertension the spasm involves the renal vascular system, in asthma,
the pulmonary, in colitis and ulcer conditions, the gastrointestinal
vascular system. At all events the problem is one of the structure of
specific action syndromes and their autonomic accompaniments. We
are led to this conclusion from the traumatic neuroses where we saw
these action systems broken up. Meanwhile the data collected by the
above mentioned authors cast much light on the occurrence of these
defective action systems in individuals who otherwise, in their inter-
personal relations, preserve a good deal of infantilism. Those reac-
tions connected with the gastrointestinal system seem a bit more
complex; here the utility of the organ function is perverted to some
use of the organism as a whole, in the interest of evading a certain
anxiety situation.
The development of the action syndrome and its autonomic ac-
companiments ought to be studied genetically. Recent work in physi-
ology’ indicates that the functions controlled by the autonomic system
are unstable at birth and only by experience acquire the efficiency seen
in adults. In this development many mishaps may occur. Some of
these mishaps can already be observed in the early months of life.
The skin conditions after weaning are a case in point. One such case
I studied had a traumatic eczema for twenty years, beginning with
weaning, when it gave place to asthma.
The last problem in dynamics is to explain that phase of the con-
sequences of his inhibitions which ends in the claim for and dependen-
cy on compensation. This is a true secondary gain of illness, in some
*See W. B. Cannon, “The Wisdom of the Body,” pp. 301-302.
PSYCHODYNAMICS } 193
instances so powerful as to decisively interfere with any therapeutic
efforts. From what we already know of the pschopathology of trau-
matic neurosis, this dependency is an inevitable consequence of the
contraction of the ego. The claim to be supported is psychologically
justified by the complete inability of these patients to function nor-
mally. In this respect they are like children who are unable to look
after themselves. In many instances, however, where the neurosis is
chronic, and the adaptation on this contracted niveau allowed to sta-
bilize with the condition of being compensated, therapeutic efforts are
countered by the most violent resistance. And rightly so, since com-
pensation is regarded as the only means of support possible, again
because of the altered conception that the individual has of himself.
The outbursts of aggression when compensation is withdrawn are
always violent, at times even dangerous for the therapeutist. This
issue We can take up in a subsequent chapter.
NosoLoGICAL CoNSIDERATIONS—1 HE PHYSIONEUROSES
We can now turn to the question: What kind of an entity is the
traumatic neurosis? It is not a transference neurosis (anxiety hysteria,
compulsion neurosis); nor is it a “conversion” hysteria. To classify
it as a narcissistic neurosis would give us a vague qualitative standard
but no information about the special configurations of the neurosis.
What gives these conditions the right to be called “neuroses” is
the fact that they are essentially alterations in adaptation, with under-
lying inhibitions and modification of adaptive systems which miscarry
—symptoms, and changes in fixed habitual modes of values, attitudes
and behavior contingent on them—character traits. These character-
istics they have in common with anxiety hysteria and compulsion neu-
rosis.
They differ, however, in where the break in adaptation occurs, in
the specific executive systems subject to inhibition, and the connection
of these systems with the “internal environment,” the mental images
in which these executive systems are represented, and the types of
psychic elaboration to which they are subject. In hysteria and obses-
sional neurosis the break in adaptation is in specific integrative systems
194 THE TRAUMATIC NEUROSES OF WAR
dealing with sexual impulses, relation to others, control of aggres-
sion, and so on. The psychic representability of these is very rich, the
elaborations of which they are capable infinite in variety. In these
neuroses the elementary adaptations to the outer world are secure,
and, with the exception of conversion hysteria, body ego action syn-
dromes are not much involved. In the traumatic neuroses the refer-
ence is chiefly to body ego, the psychic elaborations being poor,
though the executive apparatus involved is the immediate sensory-
psychomotor apparatus. So far so good. But difficulties immediately
arise if we attempt to make these criteria the basis of a nosological
differentiation.
No sharp dividing line can be made between these two orders of
neuroses. The principles of psychopathology are quite the same in
both, and the executive systems involved always intermingled. The
basic structure of both neuroses is essentially the same: an inhibition
followed by an alteration in ego structure to accommodate to the
change in adaptation possibilities. The phenomena vary only in ac-
cordance with the psychic representability of the impulses involved,
whether they are related to the social environment or the outer world,
superego or body ego, whether or not the deleted activity can be sub-
stituted and whether the entire personality can alter itself to fit the
new situation. In the case of the transference neurosis the opportuni-
ties are much better.
Nevertheless there is an important nosological issue, and for the
sake of clarity, and if only to indicate where the predominant issues
lie, a nosological differentiation is important. This is especially so
because of the tendencies in psychoanalysis to describe nosological en-
tities in terms of content. Thus we find an Oedipus complex in normal,
hysteric, schizophrenic and character disturbances. The libido theory
furnished a number of concepts such as anal sadistic fixation, narcis-
sistic, pregenital conversions, and so on, which again only stressed
content or quality. This was due entirely to the constructs made neces-
sary by the use of instinct as an organizational concept. In these phys-
ioneuroses, of which the traumatic is one, such designations according
to content ignore the configurations of the neurosis. In short, the old
classifications could not tell us why one Oedipus complex terminates
PSYCHODYNAMICS 195
in an obsessional neurosis and another in epilepsy. Freud made an
early attempt to describe the “Actualneurosen,” and in this category
were anxiety neurosis and neurasthenia. In connection with these neu-
roses Freud noted irritability, a diminished ability to tolerate accumu-
lations of excitation, auditory hyperesthesia, anxious expectation,
hypochondriasis, paresthesias, vasomotor disturbances, and so on.
The essential pathology Freud considered an “accumulation of ten-
sions which was prevented from motor discharge.” The term “ac-
tual” does not describe very much, and I would suggest the term
physioneurosis instead, because it describes more precisely the province
of the ego involved, that connected with organ function, and the spe-
cific psycho-physical integrations.
However, to say that there are pure physioneuroses would be mis-
leading; just as it would be to say that there is a pure psychoneurosis,
without physioneurotic elements. If we predicate that a neurotic proc-
ess always involves only a selective number of aspects of the ego,
then there is no theoretical reason why such a neurosis should not
combine psychoneurotic and physioneurotic elements. Such a case was
described on p. 101. When we describe a neurosis as a physioneu-
rosis we are merely indicating that certain types of ego function are
predominantly involved.
There are several additional problems that are related to the one
of the physioneurosis. In the study of hysteria and compulsion neu-
rosis the somatic manifestations were interpreted in accordance with
the rdle they played in connection with sexual conflicts—as substitutes
for genital activity, or in some other relationship to them. Thus the
content—in this instance sexual—was the sole guide. With regard to
the form, namely whether the activity involved the mouth, gastroin-
testinal tract, and so on, the physioneuroses were generally accounted
for on the basis of regression, in accordance with the tenet of the libido
theory. Insofar as these physioneurotic aspects involved oral and anal
activities, not much difficulty was encountered. But when the physio-
neurotic elements moved away from these zones, as in asthma, hyper-
tension, skin lesions, the libido theory interpretations became more
tenuous. The asthmatic spasms were most commonly related to oral
activities, skin lesions to sexual, and so on. In other types of physio-
196 THE TRAUMATIC NEUROSES OF WAR
neurosis, like hypertension, the “aggressive instincts”? were consid-
ered involved. All of these earlier explanations ignored the specific
organic integrations involved and drew their meaning from some
secondary process. More recent work by Alexander, French, Dunbar
and others is correcting this early oversimplification.
I believe the problem can be clarified if we consider that these
physioneurotic integrations are highly specific for each individual. It
would be desirable to know first why a particular psychosomatic inter-
relationship is singled out; second, what determines its form; and
finally, the (secondary) method in which it can be pressed into some
service. The latter is often not apparent.
A second problem connected with the physioneuroses is what clini-
cal forms do they take? The traumatic neurosis is perhaps the simplest
of these neuroses, and indeed, of all neuroses, because of the absence
of highly complex combinations. In the course of these neuroses there
are, however, a sufficient number of “complications” which indicate
the direction in which these neuroses proliferate. Among these com-
plications are:
I. epileptic conditions.
2. striped muscle spasms.
3. gastrointestinal group—peptic ulcer, spastic colitis, mucous
colitis.
4. autonomic imbalances of all kinds, including fluctuations in
metabolic rate, Graves’ disease.
. vasoneuroses, migraine, hypertension.
neurasthenia.
. neurodermites—angioneurotic edema.
. respiratory—asthma.
g. internal secretory—diabetes.
10. allergies.
These proliferations of the basic physioneurosis cover a wide range
of functions; but it is not farfetched to assume that all these function
systems are interconnected, largely through the autonomic system.
These conditions cannot, however, all be considered parts of the basic
physioneurosis; they may be organic complications engrafted upon it.
Hypertension may be a case in point. The vascular hardening seems
COM NN
PSYCHODYNAMICS 197
in many cases to be secondary to the “functional” process, after years
of standing.
The following brief case history indicates the complicity of these
reactions following trauma.
A child of two and one-half years was struck by an automobile. Immediately
thereafter he had a nystagmus, third nerve weakness, facial weakness, and
head lacerations. He was unconscious for a few minutes and stuporous for
several hours after. Within thirty days recovery was complete, as judged by
complete disappearance of cranial nerve signs.
Then followed a series of behavior disturbances: marked irritability, sensi-
tivity to noise (the sound of a locomotive would drive him to distraction),
easily awakened, restless sleep, and refusal to eat. He couldn’t play with other
children as before the accident. His play was changed; impatient, he dropped
things easily and broke them. Previously a contented, healthy, and happy child,
he now whined easily, was constantly discontented, and clung to his mother
all the time. He was shy and less enterprising than before.
Before the trauma he was on good terms with his little sister; now he was
cross and irritable with her, and would assault her mercilessly. He often tried
to gouge her eyes out, would step on her neck and walk on her abdomen.
Prior to his injury he had a slight eczema in back of his ears. As a result
he was tested for allergens and reagens, and was not found sensitive to any.
After the trauma he was again skin tested with the same allergens, owing to
gastrointestinal disturbances, and found sensitive to fifty percent of the aller-
gens tested. He began to have respiratory difficulties, asthmatic attacks, constant
tearing of his eyes, conjunctivitis and constant nasal discharge. He began to
have diminished resistance to illness, frequent colds, grippe. He developed a
secondary anemia, a septicemia associated with cervical glandular infection.
He had to be operated on, transfused, and treated with sulphanilamide.
One year after the trauma he still remains slightly irritable and restless;
he treats his sister better; his rhinitis has cleared up and food allergies are di-
minishing.
What are the sequelz of the trauma in this case, and what are the
sequelz of the “organic” injury? Many of the manifestations we have
already encountered in the traumatic neuroses where no question of
brain injury was present. They are, therefore, due to damage to an
adaptation, and not to tissues.
The chief interest in this case at this point lies in the limits of the
neurotic reaction, for there are two which are new and undoubtedly
secondary—the allergies and the general diminution of resistance
198 THE TRAUMATIC NEUROSES OF WAR
to infection. The allergies seem to be related to the autonomic dis-
turbances and the general diminution of resistance to the collapse of
adaptation generally.
In short, in the physioneurosis we have the following succession of
events: a break in adaptation, with a series of underlying inhibitions;
the consequences of these inhibitions, introducing a series of disor-
ganized reactions; secondary to these, certain somatic consequences
whose physiological connections cannot yet be completely traced.
These latter seem consequent upon the initial autonomic disturbance.
The nature of the “secondary” organic disturbance varies, and some
highly plausible hypotheses about the choice are now being worked
out.
In the physioneurosis we have, therefore, an entity which lies in
between pure disturbances in adaptation, and organic “disease”’—
meaning, of course, only autochthonous diseases. It is, however very
difficult to make a transition from these organic conditions as compli-
cations of traumatic neuroses, to those which occur without any iden-
tifiable trauma. In some of these conditions, notably epilepsy, Graves’
disease and diabetes, the incidence of trauma or emotional shock in
setting off the disease, is very common. To this question there are two
possible answers: 1) that they may be started by other means than
traumatic, 2) that the inhibitions which are at their basis can be initi-
ated by circumstances that do not appear traumatic and are, therefore,
very difficult to identify. The only way to find the answer is to study
the adaptation of subjects with these illnesses with great precision and
detail, in the hope that the break in adaptation and the consequent
inhibitions can be more precisely located.
SUMMARY AND CONCLUSIONS
The traumatic neurosis is the simplest of all neuroses. Notwith-
standing its simplicity the skeletal structure of this neurosis proves to
be quite the same as that encountered in the character neuroses. The
difference between the two depends largely on the nature of the
adaptive processes in each case which happen to be involved. The
difference between the two types of adaptive processes can be illus-
trated by the contrast between the two propositions: “How many
PSYCHODYNAMICS 199
ways are there to get along with father?” and “How many ways are
there to hit a nail on the head with a hammer?” In the first case the
adaptive maneuvers consist of kaleidoscopic changes in attitudes in-
volving the control of autochthonous impulses all of which enjoy a
varied and rich apperceptive representability. In the second there is
largely a body ego component which can be appraised by physio-
logical criteria and has a poor apperceptive representability which
consists of only two modalities, namely either doing the act or failing
to do it.
The traumatic neurosis is the record of the lasting consequences of
an abrupt change in the external environment to which the resources
of the individual are unequal. This situation we designated as trauma.
The neurosis is, therefore, the record of the disturbance created by
the trauma on the previously established adaptations. Secondly, it is
the record of persistent and unrelenting efforts at restitution. These
are the crucial events of the neurosis. The manner of recording or
tabulating these events was contingent upon a certain methodological
framework of constructs. Two aspects of this method are crucial: First,
the genetic point of view and secondly, the point of view of the per-
sonality as a whole. The genetic point of view was essential in order
to identify a) the manner in which the activities in question were syn-
thetized and b) to identify the products of their breakdown.
The point of view of the personality as a whole was qualified by
the use of certain operational units and of certain assumptions. We
used first of all the construct ego, which means the personality as a
whole from the point of view of direct experience and connotable by
the pronoun “I.” The assumption that we made in connection with
this construct was that the ego is the product of experience and not a
thing apart from it. This means in effect that the constellations es-
tablished on the basis of the pain-pleasure principle qualify all sub-
sequent adaptations. Furthermore we discarded the concept instinct
and replaced it with the concept drive plus action syndrome and since
the former was implicit in all action syndromes it ceased to be a dif-
ferential. The action syndromes that we studied in this particular
neurosis did not take in all the activities of the ego. It only took in one
narrow portion of it, namely that connected with the body-ego func-
200
THE TRAUMATIC NEUROSES OF WAR
tions of orientation, motility, manipulation. Those aspects which make
up the character of the individual, insofar as interpersonal relations
are concerned, were not touched upon at all.
TABLE 1
Uninhibited Activity
No obstacles (anxiety) leads to—
Release of tension
Inhibited Activity
Obstacles interposed (anxiety)
No release Replaced by anxiety
Gratification No gratification + or unsatisfied ten-
Pleasure No pleasure sion, irritability
Attitude to impulse Attitude to impulse
Confidence Lack of confidence
Anticipation of gratification
+mobilization of motor and mnemic
Anxiety
Anticipation of danger
images Timidity inability to conceive of one-
+picture of oneself as consummating self as successful. Activity repre-
act sented by opposite (pain)
+constellation “I can do that.”
Accessibility Accessibility
Free, mobile, plastic Not accessible, fixed, unplastic
Representation—
Masochistic imagery
Consequence—
New adaptation made necessary
We studied first the development of these action syndromes
(Chapter IV) and then those factors which disorganized them (trau-
ma). Then we studied the essential pathology (inhibition) and finally
the consequences of the inhibition in the form of a new adaptation.
The concept inhibition had to be accepted as a datum, for nothing
definite is known about the exact mechanism whereby it is instituted,
although the process of avoiding pain is a self-evident reflex. Whereas
there are no mysteries about its purpose or its provocation—some
form of anxiety—the techniques by which it is effected in complicated
reactions which are under no voluntary control still remain very ob-
scure. Flowever, they are no more obscure than the manner in which
strong defensive functions are mobilized in the organism over which
the individual exercises no conscious control. To mention only a few
of these—leukocytosis, immunization, etc. These really illustrate the
same principle. The ignorance of how this is effected does not prevent
us from identifying the fact and following the sequelae.
PSYCHODYNAMICS 201
One of the advantages we gained from the study of the integration
of the action syndrome was that we were able continuously to observe
the operation of the pleasure principle in its creation. It was this fact
which elucidated the effects of the trauma and which made the signi-
ficance of the compensatory efforts apparent. During the process of
growth there is plenty of opportunity for choice in the event of failure
except for the elementary functions of orientation and locomotion;
but once the action syndrome is fixed by success new adaptations are
more difficult to establish in the event that anxiety compels their
abandonment. If, for example, vision is inhibited the function of
vision is totally lost to the organism. Compensatory efforts may be
made by pressing other sense organs into service but they do not have
the quality of vision. We also observed in connection with these inte-
erations the possibility of deriving gratification from faulty integra-
tions. This is, however, the rare exception (see pp. 123-129).
The inhibitory processes and their sequel were studied by a) the
identifiable products of the breakdown into effects on the personality
as a whole (Table 1) and by b) contrast with the character neuroses
(Table 2). The contrast demonstrates that the motive for inhibition
is the same in both (anxiety, fear or fright) but that the technique of
inhibition differed. In the traumatic neurosis it was by contraction of
ego functions; in the character neuroses, which deal more with
autochthonous stimuli coming from biological needs and their apper-
ceptive representations, the technique was repression. In the traumatic
neurosis the consequences of this contractile process was that: 1) The
individual’s unconscious conception of himself was altered; 2) the
meaning of the outer world becomes altered; and 3) the internal
regulating apparatus governed by the autonomic system is thrown out
of consonance with the voluntary system, which is now blocked par-
tially or completely. The gross significance of these contractile proc-
esses is that the effective ego is now altered as to size—it is smaller,
and altered as to adaptive possibilities—they are distinctly fewer. It
is, therefore, to be expected that the new adaptation is compatible with
the new shrunken ego. This adaptation can be characterized as dis-
organized, mixed with regressive elements which cannot, however,
yield any gratification except those which depend on the reéstablish-
ment of a parasitic existence.
202 THE TRAUMATIC NEUROSES OF WAR
The most challenging of all the phenomena encountered are those
which deal with the disturbances in the autonomic system. Their sig-
nificance is heightened by the fact that the chronic and persistent dis-
orders of this system may have secondary organic sequelae.
TABLE 2
Traumatic Neurosis | Character Neurosis
Inhibition Inhibition
Technique—ego contraction Technique—Repression
Motive force—anxiety—need to pre- | Motive force—anxiety—social control or
serve body: outer world balance internalized superego
Motive—Defense Motive—Defense
Consequences of Inhibition Consequences of Inhibition
Regression—oral mastery, Regression—erogenous zones
etc. Displacement—abundant
Displacement—scanty Passivity—expedient
New Ego | Passivity—inexpedient New Ego | Character changes—innumer-
Structure ; Character changes—agegres-| Structure able variations
sion, irritability Symptoms — legion — altered
Symptoms—defensive rit- conception of relations to
ual or tic, sensory-motor, others and of own capacities
autonomic, epileptiform,
altered conception of
outer world and of self
This chart indicates that the two types of neurosis have the same basic
structure, the differences depending on the character of the particular action
syndromes which are blocked, and the opportunities for a new organization
to take the place of the one abandoned.
The disorders of this autonomic system can be classified roughly in
how they correspond to the normal physiological accompaniments
of anxiety. Such a picture is found in the usual autonomic imbalance
or what is called by Lewis the soldier’s heart or “effort syndrome.”
This autonomic picture may or may not be accompanied by the affect
of anxiety or terror in the chronic forms of the disturbance. The affect
of anxiety may completely disappear and in fact in proportion as it
disappears the more obtrusive these autonomic disturbances may be-
come. In place of the anxiety or terror there remains a residual and
PSYCHODYNAMICS 203
ever-present irritability. In the chronic cases the affect is generally
not present nor are there any displacement phobias. But there is one
constant always present in the traumatic neurosis, that the motility is
always blocked or guarded while the need tensions which can only be
released by activity continue unabated. Hence one can regard these
autonomic phenomena as evidence of stasis since the autonomic system
is not susceptible to inhibition—at least not by the same quantities of
stimuli that are effective in inhibiting the skeletal system.
There is, however, another group of autonomic disturbances which
are distortions of the normal physiological anxiety picture. And be-
yond recognizing this fact no definite clues exist. Whether these dis-
tortions are due to quantitative factors, that is greater intensity of
stimuli or whether they are due to failure in the development of the
action syndrome, this is still very obscure. These autonomic distur-
bances involve exaggerations of the activities of the gastrointestinal
tract, vascular crises in the skin, lungs, kidneys and endocrine system
leading to Graves’ disease and perhaps to allergies. The occurrence
of these phenomena in character neuroses, as demonstrated by Alex-
ander, Dunbar, e¢ a/., points to the action syndrome as the seat of the
trouble. They all have in common some motor executive inhibition
somewhere in the adaptation of the individual.
This conception of the pathology of the neurosis makes the catas-
trophic dreams and the outbursts of aggression intelligible. The first
illustrates the altered conception that the individual has of himself.
It is a well-established fact in the character neuroses that inhibitions
do alter the individual’s conception of himself, a conception which,
moreover, cannot be overcome by fantasy. This can be easily seen in
the dreams of hysterical subjects. The sadistic and masochistic phe-
nomena can likewise be explained on the basis of ego disorganization,
rather than on the basis of a change in the instinctual drive. (See
Table 3.)
The last step in the neurosis is the effort to make the new adap-
tation useful.
The traumatic neurosis raises a nosological problem, notwithstand-
ing its similarity to the character neurosis in its psychopathology. This
difference lies in the particular functions involved. Since the difference
lies in the fact that the traumatic neurosis concerns chiefly body ego
204
TABLE 3}
THE TRAUMATIC NEUROSES OF WAR
Normal-Action Syndrome
Perception by sense organ
combinations +Coérdina-
tion-+meaning =utility
Objective—exploit, avoid,
manipulate, master,
use, destroy, render
ineffectual
Attitude (to object)—in-
terest
Coérdination +-interest =in-
vestigation (curiosity)
Executive—Somatic organ,
whole motor apparatus
Technique—muscular co-
ordinative memory pic-
tures visual + kines-
thetic elements +
knowledge of past suc-
cesses.
Internal concomitants—au-
tonomic activity
Accessibility to ego—free
Modifiability—capable of
modification—skill—
inventiveness
Effect on ego =self confi-
dence, enterprise, “I
can do that,” ego en-
hancement, pride, satis-
faction
Control—By external sense
of reality+integrity of
physical apparatus —ex-
cept normal fatigue
Trauma
ing
Meaning—lost
Objective—flight
Attitude—fright, fear,
panic, collapse
Totally lost
Lost—loss of con-
sciousness, paralysis
or outburst of dis-
organized aggres-
sion
Conditions of disor-
ganization
Impeded
Impeded
Feeling of dissolution
External reality over-
whelms ego
Altered Action Syndrome
Chronic Effects
Perception overwhelm-| Perception—may be
dulled and confused
meaning modified,
utility is lost
Objective—lost
Wish to have done with
or to get away from
Anxiety and irritability
Executive system—
greatly impaired;
permanent local or
temporary total
Overactive but disor-
ganized, not conson-
ant with external ac-
tivity
Not readily available—
inhibited
Slow recuperation, but
not to erstwhile state
Self confidence gone,
internal picture of
helplessness, no pic-
ture of completion of
act, continued frus-
tration, no pride
External reality is over-
whelming
Secondary
Effects
Diminished interest in
the world
Disorganized activity
—explosive out-
bursts; _— epileptic
seizures; paralyses
dis-
All autonomic
turbances
See p. 196
Work inhibitions
Catastrophic dreams
Limited intellectual
and physical activ-
ity
* The necessity of tabulating the comparison between the normal action syndrome and
the effects of trauma unfortunately destroys some of the interconnections between the
various elements of the action syndrome itself.
The normal action syndrome is made up of perceptual, codrdinative and executive
elements. All of these together constitute an integrative unit. T hrough the interaction
of these various elements objects in the outer world acquire a special meaning, namely
utility. In the relations to the objects in the outer world one can discriminate various
PSYCHODYNAMICS 205
action syndromes and the character neurosis is concerned chiefly with
the government of autochthonous impulses and the relations to others,
a nosological differentiation is justified. Hence the name physioneu-
yosis was suggested. Physioneurotic mechanisms are present in all
neuroses and the name of the neurosis merely indicates the domain
predominantly involved.
Our final problem is the one with which we started, namely, how
is this theoretical concept of the traumatic neurosis reconcilable with
the general theory of the neuroses? The only change made was the
supplanting of the operational concept instinct, a conative principle,
by the action syndrome, a morphological principle. This led to an
abandonment of the approach of adaptation from the point of view
of the pursuit of instinctual goals to that of the organizing apparatus,
the ego. From this point of view the growth and development of
adaptive maneuvers could be observed in all aspects of adaptation—
the physical and human environments.
These two aspects of development are simultaneous, and mutually
influence each other. There are many vicissitudes in both. Those most
thoroughly studied were the satisfaction of biologically determined
needs (hunger and sex) in relation to the human environment. The
influences of frustration and consequent repressions have been thor-
oughly studied. Similar failures can occur in the adaptations to the
outer physical world; but here the child has, except for a few basic
adaptations like orientation, a wide range of choice to develop one
aptitude as against another. The principles of integration are the same
in both aspects of adaptation, and the consequences of inhibition fol-
low similar lines in both. The traumatic neurosis is one consequence
of the inhibition of fixed body ego functions, which once established,
cannot be replaced. The modality of passivity is not successful, except
in the one form of utilizing the reduced capacities as a claim for sup-
port.
forms of utility, namely to exploit, to avoid, to manipulate, to master, to use, to destroy,
to render ineffectual, etc. The attitude to the object is one of interest. An integral part of
the action syndrome is the normal autonomic activity that accompanies the other forms
of activity. The normal action syndrome is one that enjoys free accessibility to the ego.
It is modifiable in the form of higher skill. This free accessibility together with the
memory of past successes creates the feeling of self-confidence.
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VI. COURSE, PROGNOSIS, DIFFERENTIAL DIAGNOSIS
CouRSE
THE course of a traumatic neurosis is influenced not only by intra-
psychic factors but by a large number of external ones. Generally
speaking, the course of any traumatic neurosis is likely to be chronic
if it serves the patient the use of a secondary conscious or unconscious
gain. This is true of all clinical types, whether the clinical form cor-
responds to the transference neurosis or those that approximate ep1-
leptic reaction types. Of the external factors, the most important of
all that tend to render the neurosis chronic is compensation for the
resulting disability. This issue we shall consider in detail in another
chapter.
In the study of the chronic forms we encounter a great variety of
stages of convalescence. Were the course of the illness not modified
by external or secondary factors, in the greatest number of cases, I
would say, the spontaneous course of the illness is in the direction of
slow improvement. Even under the most favorable circumstances,
however, the spontaneous course of recovery is extremely slow. In a
previous chapter we referred to a case seven years old, in which we
noted that the annihilation dreams were replaced by a series of dreams
of oral frustration. This type of dream represents a considerable con-
valescence from that represented in the original annihilation dreams.
In this particular case the convalescence was aided by the patient’s
retreat from his former occupation—flight from noise, effort and
competition, to an occupation that barely kept him alive. In the ex-
pense at which his comfort is bought, this patient’s adaptation is of the
same type found in transference neurosis, where comfort 1s bought at
the price of a great many inhibitions and restrictions.
Cases of this kind represent a spontaneous “cure.” This stage, how-
ever, is the best possible result that this particular case can have with-
out treatment. Such individuals often learn to exist without compen-
Sation.
210 THE TRAUMATIC NEUROSES OF WAR
The extent of spontaneous recovery possible is determined early
in the course of the illness. Those cases which in the acute form were
marked by stuporous conditions or delirious excitements, with hallu-
cinatory episodes, as a rule improve from the acute stage, but remain
fixated in one or another form of epileptoid repetition. Once the pat-
tern is established, they tend to remain either stationary or to make
slight improvement spontaneously. Many of the cases having epi-
leptic phenomena in the first two years, improve to the extent of losing
the epileptiform reactions, but continue to have severe autonomic
crises, at times even terminating as Graves’ disease. In this stage they
are chronic. My own experience has enabled me to follow some of
these cases eight years after the original trauma.
These traumatic neuroses do not get worse with time; I have never
seen a case that was worse at the time I saw it, than at any time pre-
vious. The neurosis, having but little capacity for displacement, does
not gather new appendages or alter its surface manifestations with
the exceptions noted above.
As regards the specific types, the course varies somewhat. Those
that terminate as transference neuroses, pathoneuroses, show no traits
different from others of the same character.
The tics and defensive ceremonials are subject to long chronicity.
The latter are extremely favorable for treatment, the former much
less so.
The paralytic cases, monohemiplegias, and so on, have a chronic
and unaltering course. In the acute stages most of the paralytic phe-
nomena disappear. The aphonias, mutisms, deafness, blindness and
anosmia tend to recover in the early part of the course. But once per-
mitted to become chronic, these paralytic forms continue unaltered
and develop contractures. From the point of view of internal comfort,
however, these paralytic cases are a fortunate termination. They sleep
well and their conflict with the outer world is quieted—at a price, to
be sure. Nonetheless they establish an effective though costly, peace.
The epileptiform cases are mainly subject to a long, chronic and
unaltering course. As a group they are the least likely to spontaneous
change.
COURSE, PROGNOSIS, DIFFERENTIAL DIAGNOSIS 211
PROGNOSIS
In the acute stages the prognosis in all forms of traumatic neurosis
is good. But this is contingent upon whether there are organic compli-
cations, whether or not they are treated properly, and how much of a
role the issue of compensation is allowed to play. The experience of
Murri in the Messina earthquake indicates, that, uncomplicated by
compensation, the largest number of cases recover. Few exposed to
the trauma escaped neurosis; but most recovered within a few weeks,
almost none remaining after six months, Murri’s experience cannot,
however, be regarded as typical; the catastrophe was here universal,
conditions being the same for all concerned, (69).
The prognosis is best for transference types and worst for the
epileptiform cases.
Stammerers as a result of trauma usually represent revivals of
earlier infantile traumata. I have never seen a case of stammering
produced by trauma that was not based on a history of stammering
earlier in life. The prognosis is poor even with treatment, no different,
in fact, from stammering encountered in civilian practice.
Sensory-motor disturbances, if not recovered within six months, are
as a rule hopeless. Hypnotic treatment in the acute stages is most
helpful but not after the reaction is fixed and becomes a source of gain.
The autonomic disturbances are among the most uncomfortable
outcomes of traumatic neurosis. The efficiency of such individuals is
inordinately impaired and their discomfort constant. They do not
yield readily to treatment, being, for the greater part, inaccessible to
therapy. Atropine is a palliative in some cases.
The epileptiform types are by far the most interesting and socially
important group of the traumatic neuroses. Though not the largest
number among the clinical types, they are a social and therapeutic
problem of great importance. Quite evident from the writings of
observers of post-catastrophic conditions is that these epileptiform
cases separate themselves from the remaining conditions produced by
trauma.
The prognosis in these epileptiform conditions is good, if there is
no injury to the brain, if they are treated immediately and not per-
212 THE TRAUMATIC NEUROSES OF WAR
mitted to leave medical care before complete recovery. What inevi-
tably happens is that the basic neurosis existing, when the patient is
permitted to attempt resumption of his normal routine and is thus
given the opportunity to establish his incapacity, he is bound to accept
it and use it for all possible secondary purposes of gain. Compensation,
if it is possible, is the worst of these gains. If compensation is given
on an income basis, these epileptiform cases are rendered almost hope-
less.
The prognosis in such cases is not uniformly good. In the acute
stages it is very difficult to establish which are and which are not hope-
ful cases. There are not many criteria to use in establishing which are
the most favorable cases. Generally the most useful standard is
whether the ensuing reactions are in proportion to the severity of the
traumatic experience. An epileptiform reaction following upon being
frightened by a dud is not likely to have a good prognosis. On the
other hand epileptiform reactions following upon traumas that occur
while the subject is asleep are likewise likely to be poor.
No definite idea of prognosis in these cases can be made without an
attempt at therapy, and careful observation of how they lend them-
selves to abreducational procedures.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis is a psychiatric as well as a forensic problem.
From the psychiatric side the traumatic neuroses present very few
difficult problems in differential diagnosis. Pathoneuroses usually fol-
low upon injury of some narcissistically important organ. Schizo-
phrenia has none other than the usual standards; the same is true
of those cases where the trauma is utilized as punishment, which end
as transference neuroses.
Psychoneuroses—character neuroses. In the acute stages the pre-
dominance of displacement phobias (fear of insanity, claustrophobia,
etc.) are indicative of the fact that the current danger situation is
utilized to exaggerate old, longstanding disorders. More often the
reverse is true; severe psychoneuroses are in complete abeyance when
the subject is away from the irritating situation at home. Many a
COURSE, PROGNOSIS, DIFFERENTIAL DIAGNOSIS 213
severe obsessional neurosis tolerated the war and its severe traumata,
only to return home with the old neurosis worse than ever.
Autonomic disturbances are readily identified by the usual clinical
methods. The derivation thereof from the traumatic experience can,
as a rule, be easily determined from the dream life. Repetitive cat-
astrophic dreams are absolutely pathognomonic.
In the acute stages the autonomic disturbances are as a rule con-
sonant with the affect, terror. Their persistence after the manifest
terror subsides is often the stabilized form of the neurosis. Lewis calls
this symptom complex “the effort syndrome.” Differentiation must
be made from cardiac disease and Graves’ diease.
The sensory-motor disturbances and the epileptoid reactions pre-
sent many difficult psychiatric and forensic problems. These are the
cases in which suit for damages soon becomes the central problem in
the entire illness. The patient who develops a hemiparesis after a
trauma will, ten times out of ten, sue for damages. Then comes first
the question of the nature of the symptom: Is it “hysterical” or is it
organic? These cases are found not only in war neuroses, but very
frequently as a result of train, automobile, street car and factory
accidents.
The “hysterical” character of the symptom can be established by
the usual neurological standards which are too familiar to repeat. It
must be noted that in these cases the typical dream life of traumatic
neurosis is absent, and the patient accepts the symptoms at first with
the same “belle indifference” as in all other forms of conversion
hysteria, where the symptom is unconsciously made to serve the end
of a secondary gain. Codperation from the patient is extremely hard
to elicit in the establishment of unconscious motives. However, where
the symptom is a solution to a problem in human relations, the patient
is more likely to be codperative and permit psychoanalytic investiga-
tion.
Hypnosis is, of course, a very useful method in these paralytic dis-
turbances to establish differential diagnosis; but the patient has the
legal right to refuse hypnosis, which in either case cannot be done
without his codperation. It would be an exceedingly rare occurrence
214 THE TRAUMATIC NEUROSES OF WAR
for a patient with such a paralysis, who knows of the eventual use he
can make of his symptom, to consent to hypnosis.
In the absence of the possibility of hypnosis, observation of the use
the patient makes of the limbs or side during sleep is an excellent
substitute for the establishment of legal requirements of diagnosis.
Another method is to suddenly wake the patient out of sleep; before
fully awake these hysterical paralytics may move the affected limb.
The differential diagnosis of these “hysterical” paralyses from
malingering is along the same lines as those in established use in
neurological practice.
By far the most difficult problems in differential diagnosis are pre-
sented by the epileptiform cases. This is important from both the
forensic and the psychiatric side. The condition for which they are
most likely to be mistaken is essential epilepsy. Very definite and
distinctive criteria for such differential diagnosis, however exist:
1. How the symptom began with reference to the trauma
In the traumatic neuroses the epileptiform phenomena begin
within a few weeks after the original insult. In essential epilepsy the
connection between the two, if there was a traumatic incident, is not
likely to be so intimate.
2. What features are premonitory to the lapse of consciousness
Are the attacks initiated by external stimuli, such as noise, or
some special feature resembling the situation in the original trauma?
This latter is likely to be the case in traumatic neurosis and not in
epilepsy. It is like a finely conditioned reflex.
3. The character of the aura
In essential epilepsy the aura is usually some somatopsychic
sensation which does not appear to have connection with any trauma.
In traumatic neurosis the aura is usually distinctive, constant, a re-
production of the last sensation felt by the patient before he originally
lost consciousness. It may also occasionally reproduce a sensation
experienced after consciousness was regained.
4. The character of the dream life
In traumatic neurosis—especially in the early stages, within
the first year of the trauma—the dream life is pathognomonic. It has
COURSE, PROGNOSIS, DIFFERENTIAL DIAGNOSIS 215
the characteristics described in the earlier chapters in the book, and
usually contains reminiscences of the original trauma.
5. The character of the seizure
In the traumatic neurosis the seizure is rarely a typical epi-
leptic convulsion. The movements, likely to be codrdinated, do not
correspond to the myoclonic type. Moreover, they frequently resem-
ble movements of combat and may be associated with vocal accompani-
ments of combative excitement. There is usually no tongue biting or
relaxation of sphincters. Loss of consciousness does not set in so
abruptly, and asa rule the patients do not hurt themselves when they
fall.
It must, however, be remembered that some cases precipitated by
trauma are essential epilepsies. In these cases no differential critria
can be established. The question of legal responsibility in these cases
is difficult to dispose of. But since predisposition cannot be established,
the traumatic insult ought to be considered provocative and therefore
compensable.
6. The Electroencephalogram can be used to establish the presence
or absence of organic injury to the brain. This might be useful in
establishing positive proof in litigating cases.
7. The startle reflex (Landis) can be used to differentiate true
epilepsy from traumatic neurosis.
Malingering is likely to present difficulty only when paralytic
symptoms are simulated. In this instance surprise techniques and
hypnosis can be tried. Apart from this type, no malingerer can simulate
the syndrome of the traumatic neurosis unless he is coached. But even
in this case he could not simulate any of the autonomic disturbances.
The combination of distinctive dream life, irritability, autonomic dis-
turbances, and character changes are proof positive of a traumatic
neurosis.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
VII. TREATMENT
THE PSYCHOPATHOLOGY of the traumatic neurosis has furnished us
with a series of indications about therapeutic goals and procedure. The
fact is that although several previous methods of treatment were based
on a very incomplete conception of the psychopathology, several of
them were quite successful in the acute stage. This is notably the case
with hypnotic treatment, so commonly employed during the last war.
It is important to know why hypnosis was effectual. Most thera-
pists who did hypnosis operated on the theory that the subject was
suffering from repressed images and affects associated with the trau-
matic event. In the hypnotic sleep it was generally suggested to the
subject that he was in the original traumatic scene, and would under
these conditions “relive” the event, thus informing the physician of
the forgotten memories, which he would then impart to the subject.
This invariably resulted in considerable abreaction, which was sup-
posed to effect a cure.
However, the matter is not quite so simple, as may be proven
from the chronic cases where abreaction by itself has no curative value.
The reason is that the whole ego structure has been altered in these
chronic cases, and the abreaction, since alone it cannot alter the new
ego structure of the traumatic neurosis, is quite irrelevant. These hyp-
notic cures were successful in the acute stages of the neurosis, because
the structural changes had not yet taken place. In fact, the early hyp-
nosis occasionally stopped the automatic contractile process. This
practical bit of knowledge is often employed by aviators who imme-
diately fly after an accident, because they know that if they defer it
for a week their confidence will be gone, and they will fear going up
again.
The task of therapy in the acute cases is, therefore, to prevent the
natural defensive processes from operating, so that a new ego structure
becomes stabilized. This is the chief reason for haste in treating these
cases, and explains why the chronic cases present such difficult thera-
peutic problems—particularly when compensation for the neurosis
TREATMENT 217
has been instituted. This means of deriving a gain from the neurosis
is the most serious handicap in treatment. I have often seen patients
come diligently for treatment as long as nothing was being ac-
complished and break off suddenly when they felt it was leading to
some cure. In some instances symptoms were relieved before the
patient quite knew what was happening, and he would immediately
fly into a series of hysterical phobias. The compensation completes the
neurotic adjustment, and from his point of view the patient is justified
in his panic at recovery for now he must reassume some responsibility
for himself. Many patients will actually lie about their improvement.
AcuTE CasEs
The therapy in acute cases varies according to the presenting clini-
cal picture. The objective of the treatment must be to prevent the
neurosis from becoming stabilized in one of its contractile forms. This
can be done only by encouraging the patient to establish connection
between his symptoms, the trauma, and his now budding tendencies
to retreat. Whether the technique used is hypnosis or more direct
means does not much matter. My proference is against hypnosis, be-
cause in the acute stages it is easier to get the patient to see the con-
nection between the defensive process and the provocation. The
traumatic incident itself is the handiest material to use, and the pa-
tient’s sense of external reality and of himself should not be allowed
to change. The amnesia for the trauma is not the cause of, but only one
of the manifestations of, this altered sense of reality. The present sit-
uation of being in the hospital and under treatment must already be
interpreted by the patient as a successful outcome of the encounter,
which indeed it is.
In the comatose and maniacal cases no active therapy can be under-
taken until the subject is accessible. In the type of case described on
p. 54 the treatment must essentially be a re-education—a recapitula-
tion of the first three years of life.
TREATMENT OF ACUTE CONDITIONS
According to Dillon (64), the neuroses developing on the battle-
field are 1) fearful states accompanied by shaking, jumpiness, dizzi-
ness and headache; 2) confusional or stuporous conditions; 3)
218 THE TRAUMATIC NEUROSES OF WAR
paralyses and mutism; 4) fugue states with amnesia. The relative
proportions are: group I, 70 percent, group 3, 2 percent, groups 2 and
4, 10 percent. Most of the cases of groups 1 and 2 cleared up spon-
taneously after a few days rest. Those with fugues and amnesia were
troublesome and generally had to be evacuated. In these conditions
rest, sedatives, and hypnosis were effective in 63 percent of the cases.
A large proportion of the cases in group I recovered completely with-
out recurrence.
These fresh cases are the most important to treat immediately. For
this purpose an atmosphere of rest and assurance are of the greatest
importance. Female nurses are to be preferred to look after the gen-
eral care of these cases. The treatment should be directed to two goals:
to alleviate the immediate discomfort, and to prevent the neurosis
from consolidating.
The immediate relief must be directed to insuring rest and sleep.
But this cannot be done by the use of sedatives alone. These do help,
particularly barbiturates, which diminish sensory sensibility and be-
cause of their vasodilator effect. No time, however, should be lost in
instituting psychotherapy as soon as the patient is accessible. To com-
pel the patient to become aware that his present environment is secure,
the attitude of the physician and nurses is most important.
Cases in this stage can be treated in groups. The large number of
these cases precludes individual care. Hypnosis in groups, mild
electric shocks with the implication that it has curative value, are all
useful provided that with them are implied the protective and be-
nevolent attitude of the physician.
The ease with which these subjects can be hypnotized is in itself a
characteristic of the neurosis. It is an indication of the infantilism
which pervades the neurosis. The readiness to be hypnotized is an
indication of the eagerness with which these patients seek a protector.
The procedure is an indicator of the willingness with which they
endow the physician with magical powers in order to enjoy the
benefits of his protection.
No permanent benefits from hypnosis can, however, be expected
in any but the sensory-motor disturbances—unless it is followed up
by other re-educative measures. The function of this re-education is to
TREATMENT 219
enable the patient to see the world as it is, and to restore his confidence
in adapting to it. The combination of hypnosis and analytic procedure
is likely to be very successful in these fresh cases, because the secondary
effects of the neurosis have not yet been established. Simmel (86)
and Hadfield (64) had great success with this method. The latter
author reports 90 percent cures in the fresh cases.
The psychopathology of the disease furnishes us with the clue that
the recovery of the amnesia usually accompanying the trauma ought
not to be made the objective of treatment. This is of value only in
the acute cases. The real objective should be re-education, and to
this end activity, particularly manipulative activity should be relent-
lessly instituted.
Informal talks to groups about the nature of the illness should
follow the above measures. Mutual exchange of experiences should
be encouraged to increase tolerance for hearing of disagreeable experi-
ences. Their tolerance will naturally be small for this procedure, for
the natural defensive tendency makes them try to escape hearing
about traumatic experiences. This would also serve as an assurance
that they have not alone been the unlucky victims of disaster, and
that they need not feel especially ashamed of their reactions. An
esprit de corps can thus be created, and also an atmosphere of mutual
help. Games can also be encouraged or even made obligatory.
Numerous cases in groups of this kind will have to be removed, if
they spoil the spirit of the group, because the failure of one case may
infect the entire group with relapses. Those cases intolerant to this
procedure may have to get individual care for a time.
The greatest difficulty in these acute forms is found in connection
with those severe cases needing individual treatment. This is a tax on
the organization of a hospital staff, for these patients need at least half
an hour a day for months. A physician cannot treat more than a hand-
ful of cases at a time. It is these cases which do not respond to the crude
therapeutic procedures who are candidates for a chronic neurosis.
For the treatment of these cases the physician must be specially
trained, and have a special interest or aptitude. It is arduous work for
the physician, for he must be extremely “active” in these cases, and
often has to labor long to establish a favorable contact. These patients
220 THE TRAUMATIC NEUROSES OF WAR
are not of the kind whom one can merely invite to talk about them-
selves. They are not talkative, are generally sullen, immobile,
cramped, and their intellectual capacities contracted.
The opening step must be made by the physician; if he does not do
so nothing is likely to happen. A maternal, nurse-like attitude is
reassuring, together with inquiries about minute details about their
immediate welfare. Inquiries about food and sleep and bowels, etc.,
assure the subject of an interest which he so much needs. At the same
time an intimation that the physician knows why the patient is there,
and is thoroughly acquainted with the symptoms and the distress the
neurosis causes is a great help. One can thus come none too abruptly
to the question, “What happened?” From this point one must leave
the initiative with the patient, for he knows his tolerance better than
you do. His reactions must be respected, for they have a defensive
intent, or the case will be lost to treatment. In amnestic cases one
must begin by respecting his amnesia, and begin with what he does
remember, and allow the patient to take any direction he wants.
Inquiries about past history have no direct therapeutic value, but they
start the patient reminiscing.
Since the aim of the treatment is re-education, encouragement of
every minor achievement is important. This encouragement has a
twofold purpose: to urge him to further achievement, to guarantee
support if he needs it, to free him of the idea that the world is hostile
and that his powers to control it are gone. The patient’s unconscious
tendency is to exaggerate the physician’s powers to magical propor-
tions and that these powers are at the subject’s disposal. In this he
should not be disappointed, but this fantasy should be used to push
the patient to greater conquests. When that is achieved the fantasy
of omnipotence will disappear, and never return.
The traumatic event itself will sooner or later become a preoccu-
pation with the patient. The recovery of amnesia is always facilitated
by his current triumphs. This should always be gradual. Too abrupt
an approach will often terminate in a repetition of the original reac-
tion, and both physician and patient may be injured by the outbreak
of uncontrolled violence which this releases. The physician must be
acquainted with this possibility of violent outbursts and protect him-
TREATMENT pet
self accordingly. During this period sleep may be disturbed more than
usual, and all symptoms aggravated. This is consistent. But no oppor-
tunity should be lost to show the patient that 1) these reactions are
appropriate defenses, 2) that the world is no longer hostile, and 3)
that his powers to master it are growing.
Patients treated with the above outlined procedure are more proof
against recurrence of symptoms than those with hypnosis, though in
a field or base hospital the time factor makes hypnosis a time-saving
device.
Curonic CasEs
In chronic cases the treatment is more difficult, because we are now
dealing with a markedly altered ego structure. The following de- |
scribes the successful outcome of a chronic epileptiform case of seven
years’ standing.
The patient, a man thirty-one years old, came to the clinic complaining
of severe headaches, fainting attacks or “‘spells,”’ as he called them, insomnia,
distressing dreams, constant apprehensiveness, inefficiency, and fear of high
places. At the time he first reported to the clinic, so feeble that his wife had
to accompany him, he appeared very haggard and depressed. His story was
that his fainting attacks and general apprehensiveness were so severe that
he could make no persistent effort of any kind, could not be retained in voca-
tional training and was entirely dependent on the government for maintenance.
His attacks came at frequent intervals, occurring every day during the first
four years after the war, though only about three times a week during the
last year. The anxiety dreams, which in part caused his insomnia, were all
of the same character—falling from high places. Nothing in his pretraumatic
history was relevant to his present condition. Married in 1915, he had for a
while thereafter no regular employment. He was a first class machinist in
the aviation section of the army.
He suffered only one accident while in service, was discharged as a result
of his disability and since his return has been treated for various conditions—
pulmonary tuberculosis, neurasthenia, epilepsy; was operated on for a floating
kidney resulting from the injury; and had several other minor complaints.
All the patient’s complaints followed in the wake of the trauma that he
suffered. He was in an airplane one day, when, at a height of 3,000 feet,
something went wrong with the machine. Apparently one of the wings crashed,
and the plane began to fall. At the time he first recovered consciousness he
had a complete amnesia for all details of the fall and could only remember
awakening to find himself unstrapped from the plane and climbing up the
222 THE TRAUMATIC NEUROSES OF WAR
tail. He lost consciousness again and woke up to find himself in the hands of
a rescue party. There was an interval of several hours between the time of the
fall and the time of rescue, since he fell into a marsh which was difficult to
reach. Shortly after he was taken to the hospital he had his first fainting
attack. These attacks had since recurred at very frequent intervals.
There was no way of determining the exact nature of the attacks de-
scribed. His wife was asked to come to the clinic to give a description and from
both the patient and his wife the following account was reconstructed. ‘The
attacks lasting from twenty minutes to half an hour, were of variable in-
tensity. They could be brought on by external stimuli, such as a great deal
of noise or some other form of irritation. The patient himself supplied the in-
formation that the attack was initiated by a queer sensation in the pit of the
stomach, sometimes by a queer pain in the forehead, and was followed by a
loss of consciousness. His wife said that during the attack he was impervious
to stimuli, could not be roused, that he muttered to himself, that he occasionally
frothed at the mouth, and once bit his tongue. There were no convulsive
movements, but a kind of rigor and blueness of the face. On one occasion
he had an attack away from home, and was told by those who observed him
that he showed convulsive movements. The loss of consciousness was not al-
ways complete, the patient retaining at times some contact with the environ-
ment, though he was unable to make voluntary movements or speak. He al-
ways emerged from this attack very weak, in sweat of agony and anxiety.
The anxiety dreams which he had at night made sleep horrible, being so
distressing that he almost preferred not to sleep. They were always about
falling off some high place—mountain or building. While awake, the patient
naturally avoided all high places.
Markedly underweight at the initial examination, he had a history of
having had tuberculosis. He had several somatic injuries as a result of the
fall—a cut on the forehead and a dislocated kidney. His complexion was
dusky. Pulse rate and heart were normal. Neurological examination was
negative, except for eccentric pupils and a hemianesthesia on the left side.
Apprehensive and irritable, he felt considerable falling off of interest in the
outer world, family, and work.
The patient began by not being very codperative. Treatment for his con-
dition had become a routine matter of getting more pills and he found my
questioning decidedly unpleasant.
‘This first reaction to me was taken as a starting point. He was urged to try
to make clear to himself why the procedure was so unpleasant and of a con-
sequence made him want to stay away. After considerable fumbling the pa-
tient recognized that his reaction was due to the fact that he felt uncomfortable
while with me and had a considerable lag of discomfort after he left. The next
step was to identify the nature of this discomfort and his answer was, “I don’t
like to be thinking about those things you make me think about; I’m trying
TREATMENT 223
to forget them.” Furthermore, the “feeling worse” meant also that when
he talked to me, particularly about the circumstances of his trauma, he had a
“queer sensation in the pit of his stomach—the way I often get before I go
off.” After a little more prodding about the nature of this sensation he said it
was “like going down in an elevator very fast.” This was the first clue and I
showed him immediately that he was reproducing the traumatic event. That
is, the sinking sensation in the abdomen was actually the experience he had
in the falling plane immediately before losing consciousness.
This part of the work consumed several weeks. The patient and I then
came to an agreement that we would not press the treatment beyond his
endurance and that at any time he began to feel too sick he could interrupt
the session. This option apparently impressed the patient very much and in
the subsequent interviews I could easily observe that his tolerance was in-
creasing, as judged by the length of time he would stay. In this manner all
his hallucinatory symptoms—such as the cutting sensation on his forehead—
could be reunited to his original experience in the cockpit. At this point the
patient spontaneously recovered the knowledge of why he could not fall
asleep. He could not abandon himself to sleep because whenever he closed his
eyes, images of being in the airplane would obtrude themselves, from which
he would immediately try to get away. And this he could only do by remain-
ing awake. The patient thus got to understand that the insomnia really repre-
sented an unwillingness to abandon himself to an ever present awareness of
the traumatic situation, and that he was continually reproducing the ex-
periences he had had on the original occasion. As he learned that we could
practically reproduce at will all the symptoms that distressed him, the patient
eventually became convinced of the truth of my explanation.
A. word must be said at this point about the nature of his reaction to me.
At first I played the réle of a tormentor whom he was trying to avoid. Con-
sequent upon his first understanding of the nature of his attacks ] became a
protecting parent, this being easily discernible from the exclamations he would
utter during these first weeks of the treatment. Frequently, as he was about
to lose consciousness he would shout, “Doc, hold my hand; there I go;” and
a reassurance on my part would often abort the attack. In this way the patient
began to trust me and to follow my efforts with greater eagerness. It was
not very difficult to convince him of two important things. First, that all
these devices he was using were defensive maneuvers of a more or less reflex
and disorganized kind. And secondly, that these defensive devices were quite
irrelevant to the actual world in which he was living. Once this had been
done it was not a difficult task to show him the further consequences of his
defensive maneuvers. They were taken up in order, utilizing all the banalities
of his daily life to illustrate the point—his intolerance of his children, the loss
of aptitude for work, his lack of concentration, and so on.
Within a month or six weeks the frequence of his attacks began to subside
224 THE TRAUMATIC NEUROSES OF WAR
and the patient learned not only to tolerate but actually to rehearse the trau-
matic event, this latter to such an extent that he actually recovered most of
the details of the fall in the airplane. It must be noted here that this was not
abreaction. It was a re-education of his sense of reality, and it was due only
to the fact that the patient learned to appreciate the reality in its true form
that the therapy had any avail. Perhaps the most striking feature during his
convalescence was the fact that he was able to sleep, the disturbing dreams
ceasing both in frequence and intensity.
The treatment lasted about six months and the results achieved at that time
were truly dramatic. In addition to the above mentioned consequences were
his increasing interest in his family, his ability to participate in normal social
activities, and finally, his efforts to go back to his old occupation of being an
automobile mechanic. He could now tolerate the shock of a sudden noise,
and the backfire of an automobile would not throw him into spasms. I con-
sidered him at that time a sufficiently good result to dismiss him. I asked him,
however, to return from time to time to report on his progress and to fill in
any gaps that we might have omitted. During the next three months he re-
ported to me spontaneously once. On this occasion he told me that during his
absence he felt so completely recovered that he had even ventured to try
another flight. He made the flight without mishap. Six months after this—
that is, about fifteen months after treatment was begun—I sent for him with
the idea of checking on the permanence of the improvement. During this
interval he had been working all the time as an automobile mechanic, was
entirely self-supporting, and had had but three attacks. The first two of these
were minor in character but the last, as he put it, “was a pip... . It was the
worst attack I ever had in my whole life.” Needless to comment, my dis-
appointment was very keen. However, I asked him to describe his experience
fully and the following was his story.
“The day on which I had my last attack I got up in the morning after a
bad night. I don’t remember what I dreamed, but I did feel very blue. ‘There
was something on my mind, but I did not know what it was. I had a small
job to do that day which was to take me only a couple of hours. I didn’t feel
much like working but did, and I came back to lunch. I didn’t feel very well
and decided to take a walk. I did that for a while, then I went home. Again
I felt restless and went to a movie but did not stay to the end. I finally decided
that I would go to bed early. I slept until about 4:30 in the morning, when I
woke up suddenly with a terrific pain in my back, running up to the base of
my head, And I remember waking up crying, “George .. . George.” (George
was the name of the pilot in the plane which collapsed.) I remember seeing
my wife; I remember that she left the room and that somebody else came in
with her—one of the neighbors. She asked me what was the matter with me
TREATMENT 225
but I couldn’t answer. I didn’t lose consciousness, but kept staring into one
corner of the room which was dark and I saw something. I saw all this and
yet I was in it. It looked as if I and George started out in the plane and we
flew around for a while. Then we developed some engine trouble and had to
land. We had it fixed and then we started out again. We got just above the
clouds when I told my buddy to get down underneath the clouds. He paid no
attention to me so I took the plane from him—that is, the controls—and
began to get down under the clouds. Just as we were going down I noticed
another black object coming from the clouds. It was another plane, but we
couldn’t get away from it in time. All of a sudden we heard a crash and the
right wing collapsed, clear over our heads, and we started right down. I
couldn’t do anything; I lost all power. I thought of my buddy because I knew
he was nervous, I remembered that I had to jump. And then there was a
sensation of striking the ground and the buckle which held my strap unloosed
and I began to climb up the tail of the plane.”
Then there followed a description of the rescue party and of how the pa-
tient, after helping to pull his buddy out of the space between the motors, held
him in his lap. Then followed something in his hallucinatory panorama which
was apparently not in the original experience. The scene shifts from the falling
plane to his bedroom, where he sees his buddy alive. The latter hands him a
photograph of himself and then places it on the buffet. This ended the dream
or hallucination.
‘The patient came out of his experience weak and in a sweat. He said that
it was the worst attack he had ever had and insisted that it was not a dream
because he remembered shouting, “George;”” remembered seeing his wife
come into the room; and recalled making the effort to move and speak,
neither of which he could execute. He said that it took him an unconscionable
time to recover his composure and that when he was completely himself again
it flashed through his mind that the day of the attack was the ninth of February,
exactly seven years after the original fall from the plane. He remembered,
furthermore, that on the preceding day his wife had taken his buddy’s picture
from the wall and put it on the buffet, as happened in the hallucination.
‘This episode was quite remarkable. Such complete recovery of amnesia is
the kind that takes place only under the influence of very deep hypnosis. Sec-
ondly, it took place on the anniversary of the fall. Thirdly, it reproduced many
details of the original accident for which the patient had previously an almost
complete amnesia. Although much of this amnesia had been lifted in the
course of the treatment there were still a considerable number of details which
he had forgotten. He recalled for the first time that he was in charge of the
controls when the accident took place; that the accident was caused by a
collision with another plane; that the right wing had broken off; his concern
226 . THE TRAUMATIC NEUROSES OF WAR
about his buddy; how his buckle had become unloosed; and finally, how he
held his buddy in his lap after the rescue party had reached them. As to the
meaning of the last episode—his buddy placing his picture on the buffet—tt is
probably another way of undoing the whole traumatic incident, because it
assures him that his buddy did not die. However, no conclusive construction
about this episode could be reached with the patient. The time the patient saw
me was about a month after this last episode. He had been feeling well since
and had had no more discomforts of any kind. I had only one further contact
with this patient and that, some six months after this last reported episode. He
had been well during this entire period. On the strength of my knowledge of
his case I ventured to predict to him that he would probably never again have
another attack for the rest of his life.
To consider that the therapy consists of the lifting of the amnesia
would be an error. This cannot be made an objective of the treatment
for the reasons indicated. The amnesia is already a symptom of a
collapse in ego resources and of the continuous defensive policy of the
new adaptation. The amnesia can be lifted only when the individual’s
picture of the outer world has been changed, when his courage and
resources in handling this new external reality have been increased
or restored, at least in part, to their erstwhile state. The circumstances
instrumental in the creation of this hallucinatory episode were several.
Some were accidental, such as his wife’s taking the picture from the
wall and putting it on the buffet; another was a repetitive phenom-
enon, namely the anniversary of his fall; and finally the patient
showed in the ability to reproduce the whole original event that his
resources were equal to it without losing consciousness.
This case is of considerable social importance. Five or six years of
this man’s life were wasted, during which he was a public charge,
when the course of the case indicates clearly that he could have been
completely rehabilitated within six months, had the proper diagnosis
and treatment been supplied. It follows that if this patient were able
to get well after six years, then he surely would have been able to
recover within the first six months. However, it must be said of this
particular case that the neurosis had not become irretrievably calcified
behind a rigorous defensive ego structure. He was pervious to influ-
ence; he reacted to me as a child to a parent. But this was a favorable
circumstance. It is not unlikely that one of the things that happens in
some of these severe epileptiform cases is a calcification of the entire
TREATMENT 227
personality, including the ability to retain even a childish attitude
toward those they can trust.
FurTHER PoINts IN TECHNIQUE
The attitude of the physician in treating these cases is that of the
protecting parent. He must help the patient reclaim his grip upon the
outer world, which can never be done by a perfunctory, pill-dispens-
ing attitude. The task of the physician in taking this réle is, however,
extremely difficult if the physician is directly responsible for the
patient’s receiving compensation, for the two réles are now diametri-
cally opposed. Being responsible for the patient’s compensation on the
one hand, a réle in which the physician acts as a benefactor; and on
the other, being one who compels him to stand on his own feet again.
This latter rdle of the physician is always resented by the patient
because he regards himself as resourceless. The central part of the
therapy should always be to enlighten the patient about the nature
of his defensive maneuvers and to utilize every detail of his day-to-
day adaptation in pointing this out. Every effort should be bent to re-
educating the patient to the actual realities in which he lives rather
than to the dangerous and inhospitable world in which he fancies
himself.
Patients who become absorbed in the task of recovering their
amnesias should be permitted to do so. Thus one patient occupied
months in reconstructing a scene from fragments produced in dreams
night after night. This does no harm provided the other aspect of the
work, namely, the re-establishment of more effective contact with the
world, continues. The search for amnestic fragments can in this
manner become a pastime for both physician and patient, without
much progress being made along the other and more important front.
As regards the use of hypnosis in these chronic cases, although it
does no harm, it is unlikely to do very much good.
Does the therapy prove the conception of psychopathology? Yes,
and no. Successful therapy does not always prove that the theoretical
basis on which it is founded is correct. Many a good result is achieved
on a faulty theory, and often an incontestible theoretical basis results
in practical failure.
228 THE TRAUMATIC NEUROSES OF WAR
The therapy does, however, prove the main contentions of the
psychopathology. The fact that these dreams disappear coincident
with improvement in general adaptation, as measured by working
capacity and meaningful contact with his environment, cannot be an
accident. Also the fact that the change in adaptation is due to a basic
inhibitory process—of which the amnesia is only one of many mani-
festations—seems to be well established. But from this point on our
psychopathology is undoubtedly incomplete. The further pathology
we do not yet know—that secondary to the initial inhibitions, and
terminating in a complete occlusion of the outer world, its meaning
impoverished, and the ego continuing to function at a much reduced
level. The only way to recover these finer details would be continued
study of these chronic incurable cases. Most of the chronic cases are
difficult to treat and the results poor, though some improvement can
usually be effected. In this regard the patient described above was the
exception and not the rule.
HospiraL ORGANIZATION FOR TREATMENT
During the last war, all the powers, our own included, were total-
ly unprepared for the problems of the traumatic neuroses. This caused
great discomfort during, and expensive blunders after, the war. Not
only was the organization defective, but there was no trained per-
sonnel anywhere. The traumatic neurosis, though an established
entity, was not recognized in the protean forms it is capable of assum-
ing. The result was very confusing.
Organization is partly dependent upon the type of warfare. Plans
constructed on the basis of war techniques in 1914-18 may be useless
today. The last was a war of position, with a front line, which, though
it fluctuated, was fairly constant. This type of warfare no longer exists.
Moreover, the bombing of urban centers puts the civilian in a worse
position than the soldier.
The distribution of hospitals cannot, therefore, be made solely with
reference to the battle line, but will have to be made irrespective.
Such focal points had preferably be located far from urban centers.
The hospitals devoted to the treatment of these conditions need a
TREATMENT 229
minimum of the usual hospital equipment, but need a great deal more
of recreational and vocational therapy equipment. (Preferably they
should be subdivisions of a general hospital.) More than all else they
need to be staffed by individuals with special training, both as regards
physicians and nursing personnel.
Personnel. Physicians should be trained in neurology and psychia-
try. In addition they should have had the opportunity to witness the
treatment of these cases from reception to discharge. They should be
given courses in psychopathology of these neuroses, and inducted into
treating these cases under supervision of more experienced superiors.
No physician with a perfunctory attitude to this work, or devoid of
the necessary acumen should be allowed to treat them. Kindness,
patience, tolerance are prime requisites in the physician apart from
technical knowledge. Such a physician must, moreover, become ac-
quainted with all the psychosomatic complications of traumatic
neuroses, to prevent serious errors in differential diagnosis, and need-
less operations.
Nurses. For this women are to be preferred. A maternal attitude 1s
helpful. These should also be taught the pathology of the neurosis,
and might even assist in the treatment. They must be taught the
special emergencies accompanying the nightmares.
Recreation Orderlies. Their qualifications should be like those of
nurses.
Social workers. In postwar care the social worker has an important
réle to play. Her training should also include a thorough knowledge
of the psychopathology, and the social implications of the disease.
Hospital Selection. In the acute cases patients should be ordered by
a combing process. All should begin with the crude mass treatments.
Convalescents should be separated from cases which do not move and
taken to separate wards. Individual treatment should be reserved
only for intractable cases, and preferably treated in hospitals espe-
cially devoted to these disorders,
Records. The problem of the traumatic neurosis has many unsolved
facets. No fruitful research can take place unless it is codrdinated by
a purpose centrally directed. For this reason a research staff should
230 THE TRAUMATIC NEUROSES OF WAR
be an integral part of the organization for treatment. The problems
of such a research staff are to analyze the material with respect to
selecting and eliminating cases:
a. before induction into service
b. after induction into service
c. before active service
d. after active service
The analysis of this material may yield some information on the still
unsettled problem of predisposition or the pre-traumatic personalty.
Besides analysis of the efficacy of therapeutic procedures, an impor-
tant function of this research is the study of the postwar career of the
soldier. This is a social problem of the greatest importance.
PROPHYLAXIS AND CIvILIAN MORALE
The traumatic neurosis is not a preventable disease in the same
sense that typhoid fever is. As long as there are war, shells, airplanes,
and accidents, these neuroses will occur. In war, however, some
control over the situation can be exercised because the soldier who
succumbs to a severe traumatic neurosis gives many early indications
of the later course. Some of these indications can be used before
induction to service. Men with a history of convulsive seizures of any
kind, who are “fainty,” who “can’t stand the sight of blood,” who are
inordinately sensitive to physical pain, who “give in,” easily to physi-
cal exertion, stammerers and tiqueurs, are good candidates for trau-
matic neuroses. On the other hand these criteria are not always reli-
able, for many of the severest cases I saw were in exceptionally brave
men, with extraordinary powers of endurance, and with the exception
of convulsive phenomena, cannot be used to exclude men from service.
However, once in service they should be watched for autonomic
disturbances in ordinary routine. Exaggeration of tics, stammering,
fainting spells in service should be enough to warrant removal to less
strenuous duties. These people can be safely relegated for duty to
clerical work or in the medical corps, for the reason that being active to
others who are sick often acts as a deep restorative to confidence. The
chief reason for eliminating these men from combatant duty is that
TREATMENT 231
they decidedly spoil fighting morale, and their removal from a
company has the same effect on the others as their elimination by
death. Moreover, a convulsive attack during action will infect and
demoralize a whole company. The elimination of these men is, there-
fore, a part of good military discipline.
From this point on, prophylaxis has the objective of preventing the
incurable forms of the disease. Those with organic injury of the
central nervous system can be identified by the electroencephalogram,
and should never be returned to combatant service. Those whose
electroencephalogram is negative must be dealt with as outlined
above. The prophylaxis is really cure in the milder forms of the
neurosis.
One cannot leave the subject of prophylaxis without a considera-
tion of the traumatic neurosis in civilians living in the war zone. Aerial
bombardment places the civilian in the same position as the soldier
except that the former is much worse off, having none of the latter’s
defenses. He is that much worse off in that he has nothing to do
but wait for annihilation, than which there is no more exhausting pre-
disposing factor. Add to this the fact that aerial bombardment on
urban centers has largely the purpose of inducing neurosis, and we
have in this a major problem in mental hygiene, as well as an im-
portant war measure.
The “war of nerves,” now such a widespread instrument of war,
is a subject that needs separate treatment. Our only concern with it
is that it is one of the weapons in use today, which seeks not to destroy
the individual, but to render his opposition ineffectual. This weapon
produces a special type of neurosis which is not a traumatic neurosis;
but it does have a relation to it. It is, as Crichton-Miller aptly ob-
serves, a measure which is the direct opposite of psychotherapy. Its
intention is to produce mental disorder, and not to cure it.
The objective of the war of nerves is to render the enemy unwill-
ing to resist; to fatigue him with endless threats, to frighten him with
noise, to belittle and ridicule his combative powers, and show him
how great are your own. Among the weapons used 1s the bombard-
ment of urban centers and this is why it enters our focus.
Traumatic neuroses among civilians will of consequence be nu-
232 THE TRAUMATIC NEUROSES OF WAR
merous as a result of this type of warfare. No systematic reports have
yet come through, but the likelihood is that the incidence must be
at least as high as that among soldiers. Children and the aged are said
to have greater tolerance for traumatic experience than those in the
intermediate age group.
The best prophylactic is adequate shelter against air raids, for rel-
atively few neuroses will occur except in those at or near actual ex-
plosions. But the loss of adequate sleep and relaxation continuing
over long periods will put the civilian in the same position as the
trench soldier. Active participation in some maneuvers, some ap-
pointed duty is recommended by Crichton-Miller. This has the ad-
vantage of aiding to remove the feeling of helplessness.
SUMMARY
The psychopathology of the traumatic neurosis has taught us that
I) the subject’s conception of the outer world and 2) his concep-
tion of his own capacities to deal with it have undergone a profound
change. This is effected by a contractile process involving effective
resources. The aim of therapy is 1) to revise these reciprocal images
of self and outer world to accord with the ow actual reality and not
with that which prevailed on the occasion of the trauma; 2) to pre-
vent this altered conception of self and outer world from becoming
consolidated. Should this take place, the subject will have no choice
but to use this new ego organization as the basis of his adaptation. This
has serious personal and social consequences.
This therapeutic objective can be achieved by various means. In
acute stages group treatment is possible. It can be done with or with-
out hypnosis. The amnesia is not the cause but a consequence of the
defensive process; it should not be made the central focus of the
treatment. Amusement, occupational manipulative activity, competi-
tive games should be encouraged. Care must be exercised to separate
unresponsive cases for individual treatment.
Chronic cases present difficult problems in therapy, especially when
complicated by compensation. The principles of treatment are the
same, but might be aided by hypnosis or sedative drugs.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
VIII. FORENSIC ISSUES
ONE OF THE CERTAINTIES With which a warring nation must contend
is that at the termination of the conflict there will be a considerable
number of problems dealing with those soldiers who return more or
less damaged. One of the forms which this damage takes is the per-
sistent traumatic neurosis, The victims of this neurosis become not
merely a medical problem—a pressing one, to be sure—but, owing to
the peculiar circumstances that surround its onset and the strange
phenomena associated with its course, a pressing social problem as
well. They become a social problem largely because one of the symp-
toms of this neurosis is a persistent diminution in the capacity for
work. This is true not alone of the very severe epileptiform cases,
but of many of the milder neuroses which are merely characterized
by autonomic disturbances. The victims are a social problem because
there are difficulties of rehabilitating them to become socially inde-
pendent individuals; and because several of the conventional methods
of dealing with them complicate and aggravate the already existing
medical problem. Among these aggravating factors perhaps the most
pressing is the issue of compensation.
However, the problem of the postwar traumatic neurosis is really
not different from the same neurosis in peacetime. Hardly a traumatic
neurosis occurring in civilian life is not sooner or later complicated
by the fact that the individual feels that the responsibility for his
incapacity can and should be shouldered by someone else. In the
case of the war neuroses this responsibility is acknowledged by the
government. In the case of peacetime traumatic neuroses this aspect
is largely covered by insurance companies. In this issue the patient and
the company find themselves each defending opposing interests—
the one to get as much as possible, and the other to give as little as
possible. This situation is, moreover, complicated in peacetime be-
cause the criteria for accurate diagnosis of traumatic neurosis have
heretofore been lacking. Great decisions are made upon “authority,”
234 THE TRAUMATIC NEUROSES OF WAR
on hunches, beliefs, and opinions. Furthermore the words “hysteri-
cal” and “functional” have acquired a strange meaning in the public
eye. Not altogether without reason does public sympathy attach most
readily to obvious and dramatic disability. Disorders of the person-
ality as a whole cannot be seen with the naked eye, are difficult to
demonstrate, the diagnosis depends upon the use of criteria not even
commonly accepted by physicians; and so when the words “hysteri-
cal” or “functional” are used to characterize a neurosis its social
meaning is that the subject is a predatory individual, trying to get
something for nothing. The victim of such a neurosis is, therefore,
without sympathy in court and, with some reluctance it must also be
stated, without sympathy from his physicians, who often take “func-
tional” or “hysterical”? to mean that the individual is suffering from
some persistent form of wickedness, perversity, or weakness of will.
On the other hand, it not infrequently happens even in civilian life
that the companies which cover these claims suffer as a result of inade-
quate medical diagnosis. Many is the traumatic neurosis that is com-
pensated for indefinitely long periods by insurance companies when
the truth is that the neurosis is curable.
It all comes to this: The social problems and the medical problems
converge, and no social solution can take place unless there is a sound
medical basis for it. As the matter stands now many aspects of the
traumatic neurosis which become social problems are of such charac-
ter as can be prevented by good medical practice.
Under the conditions of war, however, where the question of re-
sponsibility it not questioned, and where the numbers involved are so
large, four immediate aspects of the problem present themselves. The
first is whether or not traumatic neuroses should be as numerous as
they are. The second problem is what form rehabilitation should take.
Third, should the patient be compensated and, if so, when and how?
Fourth, what methods should be used in dealing with the incurable
cases?
As regards the first point, there is little doubt but that the num-
ber of traumatic neuroses existing in their chronic form during the
postwar period can be very substantially reduced by adequate care im-
mediately after the trauma. However, in order to do so, a machinery
FORENSIC ISSUES 235
must exist for the treatment of such conditions, and during the last
war no such regime or machinery existed. In fact, the traumatic
neurosis occupied a kind of No-man’s land between the departments
of organic neurology, internal medicine and psychiatry, and many of
the cases were bandied about from one department to another for
years before definite diagnosis was made. Many cases received no
treatment until three, four and five years after the original trauma.
An organization for treating these cases requires time to establish.
Further, it is not enough that those who actually do the work should
be psychiatrists. A physician cannot be expected to know about the
various forms of traumatic neurosis merely because he is a psychia-
trist, since, for the greater part, these neuroses are exceedingly rare
in civilian practice. The personnel for treating such neuroses must be
trained in the principles and psychopathology before they are allowed
to handle these cases. It is of the greatest importance, both for the
patients themselves and for the government, that an organization
for treatment of the acute cases should exist, because the prognosis
in these early phases of the disease is excellent if treatment be in-
stituted before the neurosis is permitted to become stabilized. Six
months after the trauma is already, in many instances, too late to
begin treatment with much hope of complete recovery. In short, the
first social aspect of the problem of traumatic neurosis is that it is a
disease which is for the greater part preventable.
Even should such an organization exist, a considerable number of
cases diagnosed as traumatic neurosis will not yield immediately to
treatment. It is difficult to state percentages, but my guess would be
that at least fifty to sixty percent of traumatic neuroses—Hadfield
says 9O percent—can be completely rehabilitated by prevention. The
treatment of these chronic forms would require a large organization
of trained psychiatrists. With all this, the prognosis in many of them
would remain extremely dubious. The problem then becomes what
is the next best thing to do with these cases if one cannot cure them.
One can rehabilitate such patients by seeking to give them work suit-
able for their diminished capacities. This is a problem for vocational
guidance experts, but from the point of view of psychiatry it is im-
portant that these individuals should be re-engaged at any cost in
236 THE TRAUMATIC NEUROSES OF WAR
some form of activity. A third method of dealing with the problem
is compensating the disabled veteran by either the lump sum method
or the income method.
After the last war the issue of compensation in traumatic neuroses
created many embarrassing situations for patient, for government
and for physician. The procedure was generally routinized. Income
was given in proportion to the apparent disability and after a variable
time this compensation was reduced, very often without any definite
results from therapy. The results of this procedure were very un-
satisfactory because, on the one hand, many veterans abused this
opportunity to exploit the government; and, on the other hand, many
permanently disabled individuals were mustered out of treatment
which was wholly ineffectual, and allowed to drift on their own re-
duced resources.
These embarrassing situations would not have arisen had there been
a machinery for the diagnosis and care of traumatic neuroses within
the first six months after their onset. By far the most important for-
ensic aspect of the traumatic neurosis is that it should not be allowed
to become stabilized. The victims should be treated immediately and
thoroughly at the onset to insure complete rehabilitation. Soldiers
who have definite traumatic neuroses should not be sent back to front
line duty but relegated to some service in the interior. The reason
for this is that one little traumatic neurosis predisposes to another,
much more severe. The worst cases observed were those who were
“blown up” six or seven times. The diagnosis of traumatic neurosis
once established, if the individual remains refractory to treatment
for more than a month, he should be disqualified from further ex-
posure to shell fire. These cases terminate in the hopeless epileptiform
types, which are utterly inaccessible to therapy after six months and
are really permanently and totally disabled.
These epileptiform cases generally fared very badly. For the
greater part they were not diagnosed as traumatic neuroses and many,
like the case described in the previous chapter, had a history of being
treated for years as epileptics with sedatives, naturally without any
abatement of symptoms. These individuals, furthermore, do badly
if they take their cases to court and there attempt to establish them-
FORENSIC ISSUES 237
selves as totally disabled. No jury can vote compensation for total
disability to a man able to walk in and out of the courtroom, to take
his seat on the witness stand, speak intelligently and show no out-
ward signs of disability. While it is quite true that the government
must protect itself against exploitation by veterans, at the same time
it must be recognized that these cases suffer under the very grave
handicap of not appearing very sick, of having no demonstrative dis-
ability—like an amputated limb or blindness, and hence make no ap-
peal to the sympathy of a jury. Since compensation rests largely on the
idea of damage, these cases have difficulty establishing their claim.
Once the prosecuting attorney and his medical aide are able to attach
the diagnosis “hysterical” or “functional” upon a claimant, the latter
is made to bear the moral blame for the neurosis. Thus, the practical
result of diagnosing these cases as “functional” is that the patient is
without sympathy in court and without authoritative medical de-
fense.
It is quite apparent from these considerations that no adequate dis-
position of these cases can be made until the symptoms of this neurosis
are recognized, and until its psychopathology is thoroughly under-
stood. On this basis only can a rational method of dealing with post-
war care of traumatic neuroses be established. Otherwise, both govern-
ment and veteran suffer grave injustices.
On the basis of what we know in this book about the traumatic
neuroses we may attempt to answer the question of whether this
neurosis should be compensated. The answer is decidedly that it
should not. What then should be done with these cases? They should
be cured. Moreover, the treatment should begin immediately, and not
after the patient has been confirmed in his neurosis and is trying to
establish an adaptation consistent with his now reduced resources.
On this latter basis the patient has a right to claim his compensation
since he is really unable to adapt to the world as he could prior to his
neurosis. Once the patient learns that his disability can be used as a
means of compelling the world to recognize his claims for depend-
ency, it is then often too late to begin treatment with any chance of a
successful issue. Very often I was confronted in the treatment of
these cases with the most profound resistance, based entirely upon
238 THE TRAUMATIC NEUROSES OF WAR
the idea that if the patient got well he would lose his compensation.
Such a state of affairs should never be allowed to arise, and could
not were the patient considered in government service as long as he
was being treated, and not discharged until he had been rehabilitated.
Whereas this recommendation might hold for a very large per-
centage of those cases with mild traumatic neuroses treated immedi-
ately after they occur, it must nevertheless be recognized that a cer-
tain percentage will not respond to immediate treatment. There is
no qustion but that the government needs to shoulder the responsibil-
ity for the care of these cases, for, even if we assume that there is a
constitutional predisposition to traumatic neurosis, it must be em-
phatically stated that predisposition alone cannot produce this disease.
It always needs a violent precipitating factor and only the confluence
of both factors can create a traumatic neurosis.
In other words, only those cases which fail to respond to treatment
within the first six months should remain to be dealt with as problems
of readjustment. For the disposition of these cases a considerable
choice of methods suggests itself. Vocational re-training sounds theo-
retically correct and plausible, yet it often happened that many of
these veterans were no better at their new vocation than at the old.
I do not believe that most of these severe epileptiform cases can be
rehabilitated for any vocation, and these are the cases in which com-
pensation may be given.
However, the question of how this compensation should be given
is difficult to answer—whether in the form of a lump sum or monthly
installments. Perhaps the most suitable disposition of these cases,
since they are really not so numerous, would be to place them in con-
valescence camps, where they could be trained to run half self-suffi-
cient enterprises with limited responsibility and constant medical care.
In summary, we may say that the social issues connected with the
traumatic neurosis can only be established on the firm basis of an
established psychopathology which is capable of universal acceptance.
This problem cannot be simplified and surely not settled as long as
such vague concepts as “hysterical” and “functional” are allowed
to be used in connection with traumatic neurosis, and as long as it is
not publicly recognized that there is such a thing as a disturbance
FORENSIC ISSUES 239
of the entire personality which is invisible to the naked eye, which
makes no dramatic appeal, and which requires a set of experts to
diagnose and skillful treatment to effect a cure. The social problems
are chiefly those connected with the reduced capacity for work, which
means for the individual concerned a complete readaptation in his
mode of life. Compensation should properly be reserved for only
those cases proven to be incurable after treatment for two or three
years under custodial care, before the individual has learned that his
illness can be used as a means of profit. Of the various methods of
compensation, the lump sum method works out best in the long run
for the government, but not for those veterans who are permanently
disabled. On the other hand, the method of compensating by income
works out seriously to the disadvantage of the government and, in
the long run, also for the patient.
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
IX. OPEN QUESTIONS AND FUTURE PROBLEMS
THE END OF A BOOK is an opportunity for retrospect and prospect,
a chance to probe out its weaknesses and to decide on future research.
Some parts of the thesis in this book have been checked by myslf
and several others many times, and are of consequence those parts
which seem most secure. They are the clinical forms of the neurosis,
and the general outline of the therapy.
With regard to the clinical phenomenology, particularly those de-
tails which can be elicited under conditions of personal treatment,
these can be much improved. The coéperation of internists, ophthal-
mologists, otologists, rhinologists, neurologists, would greatly enlarge
on the actual phenomena of the disease. The peculiar mental charac-
teristics in the form of paucity of thought, stereotyped imagery, nar-
row range of intellectual effort, all these are traits which need more
accurate description, and may yield much to a better understanding
of the entire syndrome.
As regards the theoretical reconstruction more doubt exists. With-
in ten years I have completely altered the explanation of what oc-
curs in the creation of the pathological phenomena. This was due to
an alteration in operating tools. The general conception of the psy-
chopathology has not been altered.
It must, however, be acknowledged that the evidence for a com-
plete theoretical reconstruction is still lacking. There are too many
gaps in the material. As a result some questions remain unanswered
though some suggestions have been offered. This is notably the case
with the problem of predisposition to the neurosis. The difficulties in
solving this problem are great. The personality under investigation
in a chronic traumatic neurosis is one that has already been much modi-
fied by the neurosis, and cannot be investigated by the usual analytic
technique as long as the traumatic neurosis obtrudes itself. And after
cured they generally refuse to codperate further for such an investi-
gation. Hence the problem still waits. The character neuroses mixed
OPEN QUESTIONS AND FUTURE PROBLEMS 241
up with the traumatic neuroses are just like the character neuroses of
civilian life and hence yield nothing distinctive on this point.
This problem may eventually be circumvented by statistical com-
pilations. However, this is not possible without a large staff with a
uniform objective. This is not easy to achieve.
In the domain of therapy, the chronic cases are still a mighty chal-
lenge, especially those cases in which organic injury is well excluded.
For a time I considered that the intractable cases were those in which
transference of the usual infantile type could not be established. This
proved to be incorrect; cases with capacity for a childish trust and co-
operation proved intractable after several years of persistent effort.
The possibilities of chemotherapy in these cases yet needs to be ex-
plored.
The influence of the traumatic neurosis on the emotional relation-
ships is still poorly understood. I have often regarded the traumatic
neurosis as a kind of organic paranoia, with the outer world in the
role of the arch persecutor. Once I had the opportunity to observe
this paranoia realized in the form of a vindicative and violent jeal-
ousy of a woman whom the subject married ten years ofter his original
trauma. His neurosis was one of the severe epileptiform type. His
inadequacy toward the outer world was “displaced” onto his wife
with great violence.
By far the most important genetic problem of tracing the recipro-
cal relations between the body ego development and character de-
velopment awaits solution. The difficult problems in psychosomatics
lie concealed in how the specific autonomic patterns are established.
The interferences which the infections of childhood, especially the
severe ones of scarlet fever, pneumonia and others offer to normal
growth must be explored. The sketch we gave of body ego develop-
ment must be studied in much finer detail than was presented.
On the sociological side many problems await answer from statisti-
cal analysis of large numbers of these cases. The distribution of trau-
matic neurosis as regards age, status, education, rank, as against urban
origin, volunteer or draftee, army and navy. Comparisons with civil-
ian incidence in all levels of status and nature of trauma would be
useful. Pretraumatic history should be investigated as fully as pos-
242 THE TRAUMATIC NEUROSES OF WAR
sible. Information not available from the patient should be obtained
by social workers.
The history of cardiac, vasomotor, endocrine disturbances should
be elicited. Electroencephalogram, basal metabolism and other clini-
cal tests should be done. Rohrschach tests and general intelligence
tests should be recorded.
QuESTIONNAIRE ON [TRAUMATIC STATUS
The following questionnaire is a guide to the relevant information
on the status of traumatic neurosis.
Age
Date and place of birth
Parents—age
Siblings—age
Birth
premature or full term
character of delivery
state at birth
feedings after birth
Weaning
induced when—special reactions
Sphincter control
how inducted—reactions noted
Body ego development
rapid or slow
age at walking
teething and reactions to it
was he constantly falling?
character of play with toys
favorite games
speech development
sibling reactions
special aptitudes or failures in childhood and reactions:
intellectual growth
OPEN QUESTIONS AND FUTURE PROBLEMS
Relations to others
to mother
to siblings Details and special characteristics
to father
Schooling
began when
grades
special talents or failures
aptitudes for arts or mechanics
education continued for how long?
relationship to authority and playmates
Sexual Development
masturbation in childhood—reactions to threats
when begun and when stopped
first sexual contact
relations with women
Vocational
History of occupation
How was choice made; plan or chance?
character of work and interest in it
lose jobs, and why?
steady at work—attitudes to work, slowness or speed, interest
Marital status
character of relationship to wife and to children, to relatives
Military History—Training
volunteer or draftee
where first inducted
military record
reaction to officers—to subordinates
tolerance for work, routine, monotony, sexual abstinence
disqualified or disciplined for anything
venereal disease
A.W.O.L.
Reactions to training—fellow feeling, codperative or strange
243
special reactions—“fainty,” could he stand sight of blood, how did he
stand injury
244 THE TRAUMATIC NEUROSES OF WAR
pugnacious or passive
illnesses—how tolerated, exaggerated or minimized
character of sleep—restful, disturbed, and by what
Active duty
when sent to active duty
assignment
tolerance for shell fire, fatigue
anxiety, terror, convulsions
cardiac reactions
Urinary reactions
diarrhea or constipation
appetite and fluid intake
sweating
spasms— intestinal or laryngeal—asthma, stammering
reactions to emergencies
Traumatic History (to be repeated for each trauma)
When did it happen?
initial memory
extent of amnesia
initial reaction—stupor, excitement, fugue, terror
loss of consciousness
initial hospital reaction
kind of therapy
how long treated
returned to duty or hospitalized
Physical status
Neurological status + visual fields. Taste and smell.
Special tests
blood count
blood pressure—cardiac reserve
electroencephalogram
urinalysis
cardiac reserve test
Rohrschach test
intelligence test
startle reflex—in epileptiform cases (Landis)
Psychiatric status
facies—-rigid, flexible, smiling and laughing facies
OPEN QUESTIONS AND FUTURE PROBLEMS 245
head motion—gait and manual dexterity
attitude to physician
response to treatment
Symptoms
work history, if in civilian, or internal history of active duty between
hospitalizations
chief complaints
how long after trauma did they begin
sensory-motor
rituals
autonomic
epileptiform
Character changes
pugnacious
maudlin
reactions to fights
Dream life
catastrophic
frustration
other types
Therapeutic history
recovered
improved
unimproved
nature of residuals
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PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
BIBLIOGRAPHY
Es
ABRAHAM, K.: “The Development of the Libido” in Selected Papers.
Translated by D. Bryan and Alix Strachey, Int. Ps-A. Library, No.
13, 1927.
. ALEXANDER, F.: Psychoanalysis of the Total Personality. N.Y. and
Washington: Nerv. & Ment. Dis. Pub, Co., 1930. Trans. by Bernard
Glueck and Bertram D. Lewin.
. ALEXANDER, F. anp AssociaTEs: The Influence of Psychologic factors
upon Gastro-intestinal Disturbances. Psychoanalyt. Quart. 3:501-588,
1934-
. ALEXANDER, F.: Emotional factors in essential hypertension. PsycHOsoM.
MED., 1:173-179, 1939.
. ALEXANDER, F.: Buddhistic Training as an Artificial Catatonia. Psy-
choanal. Rev. 18:129-145, 1931. Trans. by Margaret J. Powers.
. ALFVEN, J.: Das Problem der Ermiidung. Eine psychologische Studie.
Stuttgart: F. Enke, in Abhandl. a. d. Geb. d. Psychotherapie. Med.
Psychologie, H. 6. 1927.
. Antoni, N.: War neuroses. Svenska Lakartidn. 36:2097-2100, 1939.
. Arinc, C. D. anp Bateman, J. F.: Nurturing a National Neurosis.
J. Amer. med. Ass. r09:1092-1096, 1937.
. BERNFELD, S.: Die Psychologie des Sauglings. Berlin: Springer, 1926.
Trans. by Rosetta Hurwitz, The Psychology of the Infant. London:
Kegan Paul, Trench, 1929.
. BernFELp, S.: Uber Faszination. Imago, 14:76-87, 1928.
II.
oF
Berue, A.: Handb. d. Physiologie. Bd. XVII, pp. 105-132, 69-713.
BonuorrFer, K.: “Geistes und Nervenkrankheiten.” In: Handb. d.
arztl. Erfahr, im Weltkriege, 1914-1918. J. A. Barth, Leipzig, 1922.
(Schjerning) IV.
. BresLer, J.: Traumatic neurosis according to German court decisions.
Psychiat.-neurol. Wschr. 417-453-455, 1939:
. Crark, L. P.: Clinical Studies in Epilepsy. Utica: State Hospital Press,
1917. (See bibliography there. )
. Deutscu, H.: Uber Zufriedenheit, Gliick und Ekstase. Int. Z. (arztl.)
Psychoanal. 13:410-419, 1927.
. Ditton, F.: Neuroses among combatant troops in the great war. Brit.
med. J. 2:63-66, 1939.
248
ij
18.
19.
20.
21.
22.
24;
Dae!
25.
26.
27
28.
29.
30.
qi,
32.
33:
34:
35:
36.
BIBLIOGRAPHY
Dunsar, H. F.: Psychoanalytic Notes relating to Syndromes of Asthma
and Hay Fever. Psychiat. Quart. 7:25-68, 1933.
Ever, M. D.: War Shock. W. Heineman, London, 1917.
Fepern, P.: Das Ich als Subjekt und Objekt im Narzissmus. Int. Z.
(arztl.) Psychoanal. 15:393-425, 1929.
FEepERN, P.: Narzissmus im Ichgefiige. Int. Z. (4rztl.) Psychoanal.
13:420-438, 1927. (Trans. Int. J. Ps-A., IX.)
FENICHEL, O.: Uber organlibidindse Begleiterscheinungen der Triebab-
wehr. Int. Z. (arztl.) Psychoanal. 14:45-64, 1928.
FENICHEL, O.: Hysterien und Zwangsneurosen. Int. Psa. Verlag, 1931.
(Trans. Psychoanalyt Quart. 1, 2: 1932, 1933 and Norton, 1935.)
FENICHEL, O.: Outline of Clinical Psychoanalysis. Norton, New York,
1934.
FERENCZI, S.: Psychoanalytische Betrachtungen tiber den Tic. In: Bau-
steine der Psychoanalyse I, Int. Psa. Verlag, 1927.
FERENCzI, §.: Versuch einer Genitaltheorie. Int. Psa. Verlag, 1924.
FERENCZI, S.: Hysterie und Pathoneurosen. Int. Psa. Verlag, 1919.
Translation in Further Contributions to the Theory and Technique
of Psychoanalysis. Boni & Liveright, New York, 1927.
FERENCZI, S. wiTH I. Hoxtos: Paralytische Geistestérungen. Int. Psa.
Verlag, 1922. (Psychoanalysis and the Psychic Disorder of General
Paresis, Authorized English translation by Gertrude M. Barnes and
Gunther Keil. Nery. & Ment. Dis. Pub. Co., Washington, 1925-)
FERENCzI, S, WITH ABRAHAM, SIMMEL AND Jones: Psychoanalysis and
the War Neuroses. Internat. Psycho-Analytic Press. No. 2, 1921.
=>
Frencu, T.: Psychogenic Factors in Asthma. Amer. J. Psychiat. 96:
87-101, 1939.
Frevp, S.: Formulierungen iiber zwei Prinzipien des psychischen
Geschehens, Ges. Schr. V. (Trans. in Coll. Papers, IV, 13.)
E pa S. ahaa und Psychose. Ges. Schr. V. (Trans. in Coll. Papers,
; 280:
Freup, S.: Zur Einfiihrung des Narzissmus. Ges. Schr. VI. (Trans. in
Coll. Papers, IV, 30.)
Freup, S.: Triebe und Triebschicksale. Ges. Schr. V. (Trans. in Coll.
Papers, IV, 60.)
a a: ss Verdringung. Ges. Schr. V. (Trans. in Coll. Papers,
> 4.
Freup, S.: Das dkon
omische Problem des Masochismus. Ges. Schr. V.
apers, IT, 255.)
des Lustprinzips. Ges. Schr. VI. (Trans. by Hub-
Pleasure Principle.)
(Trans. in Coll, P
FREup, S.: Jenseits
back: Beyond the
BIBLIOGRAPHY 249
. Freup, S.: Das Ich und das Es. Ges. Schr. VI. (Trans. by Riviere: The
Ego and the Id.)
. FREup, S.: Hemmung, Symptom und Angst. Ges. Schr. XI.
. FrEup, S.: Dostojewski und die Vatertétung. Almanach d. Psa., 1930.
. Friscu, F.: Epilepsie. Z. ges. Neurol. Psychiat. 103:243-255, 1926.
. GoLpsTEIN, Kurt: The Organism. Am. Bk. Co., New York, 1939.
. Graven, P.: Die aktive analytische Behandlung der Epilepsie. Fort-
schritte der Sexualwissenschaft und Psa. Vol. I. Leipzig und Wien.
. GRUHLE, H.: Epilepsie. Art. in Bumke’s Handb. d. Psychiatrie, 1930.
. Horrman, R. W.: Die reflektorischen Immobilisationszustinde im Tier-
reich. In Bethe’s Handb. d. Physiol., XVII, 690-713.
. Huppeson, J. H.: Accidents, neuroses and compensation. Foreword by
J. R. Hunt, Williams and Wilkins, Baltimore, 1932.
. IscHLonpsky, N. E.: Der bedingte Reflex. Berlin u. Wien: Urban &
Schwarzenberg. (In his Neuropsyche u. Hirnrinde.), 1930.
. JELLIFFE, S. E.: Nervous diseases following accidents. Accidental injuries
to the nervous system with special reference to the traumatic neuroses.
Repr. from Schweitzer on Trial Manual for Negligence Actions.
Baker, Voorhis & Co., New York, 1937.
. Jones, E.: Psychoanalysis. Ed. 3. Wood, New York, 1928, pp. 513-521.
. Karpiner, A.: The Bio-analysis of the Epileptic Reaction. Psychoanalyt.
Quart. rz: No. 3-4, 1932.
. Karz, D. Der Aufbau der Tastwelt. Barth, Leipzig: 1925.
. Kerpet, F. anp Matt, F.: Handb. d. Entwicklungsgeschichte d. Men-
schen. Vol. II. Leipzig: Hirzel, 1910.
. Kennepy, R. F.: Nervous conditions following accident, with special
reference to head injury. In: Practitioners (The) library of med. and
surgery. 9°439-474, 1936.
. Kuetsr, K.: Episodische Dammerzustinde. G. Thieme, Leipzig: 1926.
. Lanpis, C. anp Hunt, W. A.: The startle pattern. Farrar & Rinehart,
New York, 1939.
. Lennox, W. G. AND Coss, S.: Epilepsy. Williams & Wilkins, Baltimore.
Med. Monographs, No. 14, 1928.
. Levy, Davin: Maternal Overprotection. Psychiatry. 7, 2, 3: 1938, 1939,
1940.
. Levy, Davin: Studies in Sibling Rivalry. Res. Monog. Amer. Orthopsych.
Assn. 1937.
. Lewis, T.: Soldiers Heart and the Effort Syndrome. London, 1918-
1940.
. MacCurpy, J. T.: Epileptic Dementia. Psychiat. Bull., 1916.
248
17.
18.
19.
20.
oy)
22.
23:
24.
25
26.
27,
BIBLIOGRAPHY
Dunsar, H. F.: Psychoanalytic Notes relating to Syndromes of Asthma
and Hay Fever. Psychiat. Quart. 7:25-68, 1938.
Ever, M. D.: War Shock. W. Heineman, London, 1917.
FEepERN, P.: Das Ich als Subjekt und Objekt im Narzissmus. Int. Z.
(arztl.) Psychoanal. 15:393-425, 1929.
FEDERN, P.: Narzissmus im Ichgefiige. Int. Z. (arztl.) Psychoanal.
13:420-438, 1927. (Trans. Int. J. Ps-A., IX.)
FENICHEL, O.: Uber organlibidinése Begleiterscheinungen der Triebab-
wehr. Int. Z. (arztl.) Psychoanal. 14:45-64, 1928.
FENICHEL, O.: Hysterien und Zwangsneurosen, Int. Psa. Verlag, 1931.
(Trans. Psychoanalyt Quart. 1, 2: 1932, 1933 and Norton, 1935.)
FENICHEL, O.: Outline of Clinical Psychoanalysis. Norton, New York,
1934-
FERENCZI, S.: Psychoanalytische Betrachtungen iiber den Tic. In: Bau-
steine der Psychoanalyse I, Int. Psa. Verlag, 1927.
FERENCZI, S.: Versuch einer Genitaltheorie. Int. Psa. Verlag, 1924.
FERENCZI, §.: Hysterie und Pathoneurosen. Int. Psa. Verlag, 1919.
Translation in Further Contributions to the Theory and Technique
of Psychoanalysis. Boni & Liveright, New York, 1927.
FERENCZI, S. wiTH I. Hottos: Paralytische Geistestérungen. Int. Psa.
Verlag, 1922. (Psychoanalysis and the Psychic Disorder of General
Paresis, Authorized English translation by Gertrude M. Barnes and
Gunther Keil. Nerv. & Ment. Dis. Pub. Co., Washington, 1925.)
. FERENCzI, S$. WITH ABRAHAM, SIMMEL AND JONES: Psychoanalysis and
the War Neuroses. Internat. Psycho-Analytic Press. No. 2, 1921.
. FrencuH, T.: Psychogenic Factors in Asthma. Amer. J. Psychiat. 96:
87-101, 1939.
. Freup, §.: Formulierungen iiber zwei Prinzipien des psychischen
Geschehens. Ges. Schr. V. (Trans. in Coll. Papers, IV, 13.)
. Freup, S.: Neurose und Psychose. Ges. Schr. V. (Trans. in Coll. Papers,
IT, 250.)
. Freup, S.: Zur Einfiihrung des Narzissmus. Ges. Schr. VI. (Trans. in
Coll. Papers, IV, 30.)
. Freup, S.: Triebe und Triebschicksale. Ges. Schr. V. (Trans. in Coll.
Papers, IV, 60.)
. Freup, S.: Die Verdrangung. Ges. Schr. V. (Trans. in Coll. Papers,
IV, 84.)
. FrREuD, S.: Das Skonomische Problem des Masochismus. Ges. Schr. V.
(Trans. in Coll. Papers, II, 255.)
. FREuD, S.: Jenseits des Lustprinzips. Ges. Schr. VI. (Trans. by Hub-
back: Beyond the Pleasure Principle. )
37>
38.
39:
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
ef.
52:
53:
54-
55:
56.
57:
58.
59:
BIBLIOGRAPHY 249
FREup, S.: Das Ich und das Es. Ges. Schr. VI. (Trans. by Riviere: The
Ego and the Id.)
Freup, S.: Hemmung, Symptom und Angst. Ges. Schr. XI.
FREuD, S.: Dostojewski und die Vatertétung. Almanach d. Psa., 1930.
Friscu, F.: Epilepsie. Z. ges. Neurol. Psychiat. 103:243-255, 1926.
GoLpsTEIN, Kurt: The Organism. Am. Bk. Co., New York, 19309.
GraveEN, P.: Die aktive analytische Behandlung der Epilepsie. Fort-
schritte der Sexualwissenschaft und Psa. Vol. I. Leipzig und Wien.
GRUHLE, H.: Epilepsie. Art. in Bumke’s Handb. d. Psychiatrie, 1930.
HorrMman, R. W.: Die reflektorischen Immobilisationszustinde im Tier-
reich. In Bethe’s Handb, d. Physiol., XVII, 690-713.
Hupp.eson, J. H.: Accidents, neuroses and compensation. Foreword by
J. R. Hunt, Williams and Wilkins, Baltimore, 1932.
IscHLOoNDsKy, N. E.: Der bedingte Reflex. Berlin u. Wien: Urban &
Schwarzenberg. (In his Neuropsyche u. Hirnrinde.), 1930.
JELLIFFE, S. E.: Nervous diseases following accidents. Accidental injuries
to the nervous system with special reference to the traumatic neuroses.
Repr. from Schweitzer on Trial Manual for Negligence Actions.
Baker, Voorhis & Co., New York, 1937.
Jones, E.: Psychoanalysis. Ed. 3. Wood, New York, 1928, pp. 513-521.
KarpDINER, A.: The Bio-analysis of the Epileptic Reaction. Psychoanalyt.
Quart. 1: No. 3-4, 1932.
Katz, D. Der Aufbau der Tastwelt. Barth, Leipzig: 1925.
KEIBEL, F. AnD MALL, F.: Handb. d. Entwicklungsgeschichte d. Men-
schen. Vol. II. Leipzig: Hirzel, 1910.
Kennepy, R. F.: Nervous conditions following accident, with special
reference to head injury. In: Practitioners (The) library of med. and
surgery. 9:439-474, 1936.
Kueist, K.: Episodische Dammerzustande. G. Thieme, Leipzig: 1926.
Lanois, C. AND Hunt, W. A.: The startle pattern. Farrar & Rinehart,
New York, 1939.
Lennox, W. G. anp Coss, S.: Epilepsy. Williams & Wilkins, Baltimore.
Med. Monographs, No. 14, 1928.
Levy, Davin: Maternal Overprotection. Psychiatry. 1, 2, 3: 1938, 1939,
1940.
Levy, Davin: Studies in Sibling Rivalry. Res. Monog. Amer. Orthopsych.
Assn. 1937.
Lewis, T.: Soldiers Heart and the Effort Syndrome. London, 1918-
1940.
MacCurpy, J. T.: Epileptic Dementia. Psychiat. Bull., 1916.
250
60.
61.
62.
BIBLIOGRAPHY
MacCurpy, J. T.: A clinical study of epileptic deterioration. Psychiat.
Bull. N.Y. St. Hosp., pp. 187-274, 1916.
Massin1, L. C.: Traumatic Neurosis; evaluation in legal medicine and
in invalidity insurance. Arch. Antrop. crim. 59:502-508, 1939.
McDouaatt, W.: Outline of Abnormal Psychology. Schribner’s & Sons,
New York, 1926.
. McGraw, M. B.: Growth; a study of Johnny and Jimmie. Appleton-
Century, New York, 1935.
. Miyer, E., er at: The Neuroses in War. London, 1940.
. Monakow, C, V.: Gefiihl, Gesittung u. Gehirn. Ziirich: Arb. aus. dem
anat. Inst., 1916. (The Emotions, Morality and the Brain. Authorized
translation by Gertrude Barnes and Smith Ely Jelliffe. Nerv & Ment.
Dis. Pub. Co., Washington, 1925.
. Monaxow, C. V.: Uber Lokalisation der Hirnfunktionen. Wiesbaden:
J. F. Bergman, 1910.
. Moiuuer, L. R.: Die Lebensnerven. Ed. 3. Berlin: Springer, 1929. The
third edition has the title Lebensnerven u. Lebenstriebe, 1931. The
second edition appeared 1924 as Die Lebensnerven.
. Murpuy, GARDNER AND Lois anp NEwcoms, T. M.: Experimental
Social Psychology, 1931.
. Murat, A.: Uber die traumatischen Neurosen, 1913.
. Muskens, L. J. J.: Epilepsie. Springer, Berlin, 1926. In Monographien
a. d. Gesamtgeb. d. Neur. & Psych., H. 47.
. Musxens, L. J. J.: Epilepsy. Bailliere, Tindall & Cox, London, 1928.
. O’Brien, J. F.: Epilepsy or hysteria; a study of convulsive seizures and
unconscious states in one hundred ex-service men. Boston med. surg. J.
192:103-107, 1925.
. OPPENHEIM, H.: Lehrb. d. Nervenkrankheiten. Ed. 6, Berlin: Karger,
1913.
. Prisrer, O.: Schockdenken u. Schockfantasien bei héchster Todesgefahr.
Int. Psa. Verlag, 1931.
- Retcu, W.: Die Funktion des Orgasmus. Int. Psa. Verlag, 1927.
. Reicu, W.: Uber den epileptischen Anfall. Int. Ztschr. f. Psa. XVIII,
1931.
. Rem, T.: Der Schrecken. Int. Psa. Verlag, 1929.
. RipBLe, M. A.: Instinctive Reactions in New-born Babies. Amer. J.
Psychiat. 95:149-160, 1938.
. Rivers, W. H. R.: Instinct and the Unconscious. University Press, Cam-
bridge, 1924.
. Roserr, J.: The Mechanism and Fundamental Cause of the Epilepsies.
Arch. Neurol. & Psychiat. 9: 689-738, 1923.
BIBLIOGRAPHY 251
81. Roserr, J.: The Epileptic Seizure. Arch. Neurol. Psychiat. 27:731-794,
19209.
82. SARGENT, W. anpD SLATER, E.: Acute War Neuroses. Lancet, 2-1-2,
1940.
83. ScHitpEeR, P.: Uber den Wirkungswert psychischer Erlebnisse. Arch.
Psychiat. Nervenkr. 70:1-15, 1923.
84. SCHILDER, P.: Entwurf einer Psychiatrie auf psa. Grundlage. Int. Psa.
Verlag, 1925. (Trans. by Bernard Glueck: Introduction to a Psycho-
analytic Psychiatry. Nerv. & Ment. Dis. Pub. Co., Washington, 1928.
85. ScHILDER, P.: Das Kérperschema. Springer, Berlin, 1923.
86. SIMMEL, E.: Kriegsneurosen u. psychische Traumata. Miinchen und
Leipzig: Nemmich, 1918.
87. STEKEL, W.: Der epileptische Symptomenkomplex und seine Behand-
lung. Fortschr. Sexualw. Psychoan. 70:1, 1923.
88. UEXxKULL, J. V.: Umwelt und Innenwelt der Tiere. Springer, Berlin,
1921.
89. Wixson, S. A. K.: Modern Problems in Neurology. Wood, New York,
1929.
go. Witrkower, E. AND SPILLANE, J. P.: Neuroses in war. Brit. med. J.
I 223-225, 1940.
NOTE ON THE LITERATURE
The above bibliography is not even a fragment of the literature on trau-
matic, war, and industrial neuroses. A complete bibliography would itself fill
a volume. I have not read or digested even a portion of this literature. In this
I appreciate the risk taken. I have, however, depended on bibliographies com-
piled by others and am quite confident that no significant contribution has been
overlooked. The author of a treatise on a subject has the privilege of making
recommendations to the reader who would like to pursue aspects not covered
in his work. In this spirit I recommend the following: W. H. R. Rivers,
Instinct and the Unconscious, for an introduction to an effort to think about
the meaning of this syndrome; J. H. Huddleson, Accidents, Neuroses and
Compensation, as the best general summary of the subject up to 1932; and
S. E. Jelliffe’s article in Schweitzer’s Trial Manual for Negligence Actions.
For problems in the current war, and new experiments in therapy Emanuel
Miller’s volume (1940) is the best.
A. K.
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PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
INDEX
Abraham, K., v, 137
Abreaction, 216
Acoustic irritability, 41, 96
Action syndrome, 6, 140, 169, 170
function of, 179
meaning in relation to, 179
receptor, coordinator and effector
constituents, 179
relations of, 204
structure of, 170, 174, 177-182
Action systems, 100
Adaptation, 88
alterations in, 81
definition of, 141
disorganized, 73
in war, 72
qualitative changes, 80
Adaptive patterns
development of, 142
Adler, L., 167 n.
Aggression, 82, 96, 97, 116
guilt in relation to, 109
in relation to disorganization, 132
organized forms of, 100
outbursts of, 61, 63, 97, 108, 187
Alexander, F., vii, 160, 171, 190,
196, 203
Allergies, 196, 197
Amaurosis, 29
transient, 106
Amblyopia, 29
Amnesia
role of, 88
technique of overcoming, 102
treatment of, 220, 224, 225, 226
Anosmia, 29
Anxiety, 145
as a variable, 86
free-floating, 160
in dream life, 51
inhibitory effect of, 157
in relation to ego organization, III
in relation to frustration, 169
in traumatic neuroses, 51
Aphonia, 31
Arteriosclerosis, 77
Association
as synthetic principle, 137
Asthma, 190, 191, 195
Attention, 74, 145
Aura, 43, 44, 46, 50, 51, 66
Autonomic disturbances 82, 171
clinical forms of, 21
in relation to emotional conflicts,
190
in traumatic neurosis, 189
Autonomic system
functions of, 158, 159
relation to instinct, 158
relation to voluntary, 158
Awtokratow, 69
Behavior
as source material, 135
Bernfeld, S., 147, 418, 149, 152 n.,
153
Bieber, I., 160, 190
Binswanger, O., 29, 30
Body ego, 151, 152, 194
arrests in development of, 175
in relation to utility, 113
loss of sensation, 113
254
Bonhoeffer, K., 119
Brain tumor, 78
Bratz, 119
Cannon, W. B., 143, 192 n.
Castration complex, 5
Character changes in traumatic neu-
rosis, 115
Civilian morale, 230
Chak. Lb. P.,. 520
Claustrophobia, 12, 14
Cobb, $., 190
Comic, 88 n.
Compensation, 70, 98, 209, 216,
217, 236, 237, 239
Compulsive rituals, 84
Conative principle, 139, 205
Concussion syndrome, 4
Conditioning, 137
Confabulation, 40
Constructs, 135
Contagiousness of traumatic neuroses,
Convalescent dreams, 91, 209
Course of traumatic neurosis, 209,
210
Crichton-Miller, H., 231, 232
Curiosity, 179
Daniels, G. E., 190
Deafness, 31
Death instinct, 136, 188
Defensive ceremonials, 15, 16, 17,
18, 19, 20,.23
Delirious states, 40, 60
Dependency, 172
Depersonalization, 161
Dermographia, 39
Destructiveness, 149, 157, 176, 183
Deutsch, F., 190
Differential diagnosis
dreams as, 214
hypnosis as, 213
INDEX
traumatic neurosis, of, 212-215
Dillon, F., 217
Direct experience, 135, 199
Discharge phenomena, 87, III
Disorganization, 112
normal, fatigue as, 163
Displacement phenomena, 33, 87,
178, 195
Dreams
annihilation, of, 90, 91, 92, I10,
185, 209
anxiety in, 51
as differential diagnosis, 214
convalescent, 209, 9I
frustration, of, 90
guilt, of, 92-94
in epilepsy, 129, 130
in traumatic neurosis, 57, 89-109
wish fulfillment in, 185
Dunbar, H. F., vii, 160, 171, 190,
196, 203
Eczema
traumatic, 192
Eder, M. D., 29, 31
Effective ego, 160
functions of, 161, 171
Effort syndrome, 213
Ego
contraction of, 183, 184
integrative character of, 160
Ego function
development of, 131-176
impairment of, 122-132
relation of anxiety to, III
Ego instincts, 138
Electroencephalogram, 215, 242
Epilepsy
dream life in, 129, 130
post-war, 69
relation to traumatic neurosis, in,
117
INDEX
theories of, 118-132
Epileptic symptom complex, 36, 41
in acute stages, 36
Eros (life instinct), 136
Executive organs, 147
Explanations, 135
Failure reactions, 160
Fascination, 153, 154
Fatigue, 74, 75, 162, 171
and traumatic neurosis, 169
as normal disorganization, 163
definition of, 164
in infants, 163
Fenichel, O., vil, 139
Ferenczi, S., v, 137, 150, 167
Fixation, 72, 82, 87 175
French, Ti, 160,274, 290; 191,
196
Freud, 5., ¥, 04; (£21, 9223) 236,
137, 160, 174, 195
Fright, 95, 96, 146, 163, 179
Fright reactions, 145
Frisch, F., 118
Frustration, 139, 172
anxiety in relation to, 169
dreams of, 90
Fugue, 106
Gait, disturbances of, 30
Gastric ulcer, 190, 191
Gaupp, 21, 27, 40
Graves’ disease, 21, 25, 26
Guilt
dreams of, 92-94
in relation to aggression, 109
Hadfield, J. A., 219, 235
Hibernation, 167
Hospital organization for treatment,
228
Hypertension, 190, 191, 192, 196
255
Hypnosis
in differential diagnosis, 213
in treatment, 218
Hypochondriasis, 7, 8
Hysteria, contrast of traumatic neu-
rosis with, 193
Identification, 152, 154, 173
Imitation, 152, 154, 173
Impotence, 13, 98, 99
Inhibition, 80, 81, 85, 97, 98, 173,
178, 179, 181, 198
chronic effects of, 181, 182
consequences of, 182
contrast to uninhibited activity, in,
200
manifestations of, ii
meaning, as modified by, 182
pain, in relation to, 150, 177
partial, 162
repression in relation to, 100
role of intelligence in, 152
work, to, 98, 107
Instinct
as a conative principle, 137
as an operational concept, 5, 6,
136, 169, 194
executive, 136
in traumatic neurosis, 178
relation of autonomic system to,
158
self-preservation, of, 138
somatic source, 136
Integration, 137
Integrative processes, 144
Intelligence, 152
Interest, 179
Internal environment, 157, 170, 193
in infancy, 159
Irritability, 82, 83, 95, 96, 98, 160,
163, 203
acoustic, 41, 96
256
relation to aggression, 98
Ischlondsky, N. E., 155
James-Lange theory, 159
Jelliffe, S. E., 119
Jones, B.,¥,). 137
Kelman, H., vii
Kessel (and Hyman), 21, 26
Kinaesthetic sensations, 151, 156
Kirby, G. H., vii
Kleist, K., 119
Landis, C., 144
Laughter, 145
Lethargic states, 37
Levy, D. M., 173
Lewis, T., 202, 213
Libido stasis, 160
Libido theory, 137, 194
Liddell, H. S., vii
MacCurdy, T., 90
McDougall, W., v, 115, 116
McGraw, M. B., 173
Malingering, 215
Masochism, 178, 186, 187, 188
as ego organization, 186
contrast to traumatic neurosis, in,
187
sexual, 187
Mastery, 187
definition of, 142
development of, 146
incomplete, 175
modalities of, 142
Masturbation, 173
Meaning
alteration of, 184
as modified by inhibition, 182
Meyer, A., vii
Monakow, C. V., 143
INDEX
Moro reflex, 144
Mucous colitis, 190, 191
Miiller, L. R., 158
Murphy, G., 173
Murri, A., 211
Muskens, L. J. J., 118
Mutism, 31, 85
Myelination, 143
Narcolepsy, 37
Need tension, 143
Neurasthenia, 165, 166
Night blindness, 29
Obsessional neurosis, contrast of trau-
matic neurosis with, 193
Oedipus complex, 122, 194
Operational concept, 135
instinct as, 5, 6, 136, 169, 194
Oral mastery, 149, 183
Orientation,
development of, 144
Pain, 75
in relation to inhibitions, 150, 177
Paraesthesias, 33
Paralyses, 30
Passivity, 183
Pathoneurosis, 7, 8
Pawlow, I., 168
Personnel for treatment, 229
Phobias in traumatic neuroses, 50
Photophobia, 29
Physioneuroses, 193-198
clinical types, 196
Pleasure principle, 199, 201
Pre-traumatic personality, 172
Prognosis in traumatic neurosis, 211,
212
Prophylaxis, 230
Psychodynamics of traumatic neu-
rosis, 177-205
INDEX
Rado, S., vii
Reality testing, 179
Reflexology, 147, 153
Regression, 100, 157, 175
Reich, W., 160
Repetition compulsion, 189
Repression, 162, 175, 184, 201
in relation to inhibitions, 100
in traumatic neurosis, 101, 182
Ribble, M., 144
Rivers, W. H. R., v
Rohrschach test, 242
ochilder, P., 93, 120, 123, 147, 1545
155, 161
Schizophrenia, 9, 10
Secondary gain, 209
Security, as goal, 161
Self-confidence, 172,
205 n
Self-preservation, 4
as instinct, 138
Sensory-motor disorders, 29, 84
Shell shock, 69
Shock psychosis, 39
Simmel, E., v, 137, 219
Skill, 174, 179
Skull fracture, 76
Sleep, 162
as inhibitory process, 171
conditions of, 167
interpretations of, 166, 167
Stammering, 23, 31
Startle pattern, 144, 215
Stasis phenomena, 171, 190
Stekel, W:, 93,120
Sweating, disturbances of, 33, 39
Sublimation, 115, 174
Super-ego, 139, 174, 175
Syncopal phenomena, 83, 84
177, 179;
Tarachow, S., 160, 190
257
Theory, requirements of, 135
Ticey Fs, 82
Transference neurosis, 177
incidental to war, 10, II, 12, 13,
14, 15
‘Trauma
consequences of, 179, 180, 181
definition of, 74, 79
war in relation to, 68, 69
‘Traumatic neurosis
and fatigue, 169
anxiety in, 51
autonomic disturbances in, 189
character changes, 115
clinical forms of, 7-67
conception of, organic, 4
conception of, psychogenic, 4
conception of, psychoanalytic ex-
planations, 5
constant features of, 86
contagiousness of, 39
contrast with hysteria and obses-
sional neurosis, 193
course of, 209, 210
differential diagnosis, 212-215
dream life, 57, 89-109
epilepsy, in relation to, 117
instinct in, 178
masochism in contrast to, 187
nosology, 137, 193
of peace time, 70
Parkinsonian facies, 54
phobias in, 50
physioneurosis, as, 196
predisposition to, 172, 176, 230
prognosis in, 211, 212
psychodynamics of, 177-205
relation to epilepsy, 117
repression in, IOI, 182
sexual impotence in, 13, 98, 99
spontaneous recovery of, 209, 210
treatment of, 216-232
258
Treadway, W., vii
Treatment, as re-education, 220
hospital organization for, 228
hypnosis in, 218
of traumatic neurosis, 216-232
‘Tremors, 99
Twilight states, 37
Utility, 161
function, 112, 141, 156, 161,
174, 188
value, 112
INDEX
Vertigo, 49, 54, 56, 57, 83, 98, 99,
114
Visual fields, contraction of, 29
Vocational re-education, 238
Voluntary motion, 156
War, in contrast
activity, 70, 71
in relation to trauma, 68, 69
War of nerves, 231
Wilson, K., 118
Work, psychology of, 93
inhibitions, 98, 107
to peace-time
OF
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10 SHSONOUIN ILLYWOVALL SELL
soul EN - MWAM
GBH VO PY aOIpey\ .) 3) >
abinhi
PSYCHOSOMATIC MEDICINE MONOGRAPH II-III
THE TRAUMATIC
NEUROSES OF WAR »/.,|
BY
ABRAM KARDINER, M.D.
FORMERLY ATTENDING SPECIALIST
tt. & VETERANS HOSPITAL NUMBER 81
PORMERLY INSTRUCTOR IN PSYCHIATRY
CORNELL UNIVERSITY
AND
ASSOCIATE IN PSYCHIATRY
COLUMBIA UNIVERSITY
- 1941."
PUBLISHED WITH THE SPONSORSHIP OF THE
COMMITTEE ON PROBLEMS OF NEUROTIC BEHAVIOR
DIVISION OF ANTHROPOLOGY AND PSYCHOLOGY
NATIONAL RESEARCH COUNCIL, WASHINGTON, D.C.
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